Collaborative Care in Mental Health

Collaborative Care in Mental Health in Noarlunga
Adaire Clinic Division of Mental Health Noarlunga Health Services
Noarlunga Consumer Advisory Group and Southern Division of General Practice
Project Officer Don Tustin
Funded by Innovation Initiatives Program Department of Health South Australia
The Project aimed to extend the reflective practice that was occurring in the mental health service to include all partners in a change process, to introduce new practices and to build a quality framework.
Collaborative Care in Mental Health in Noarlunga
Adaire Clinic Division of Mental Health Noarlunga Health Services
Noarlunga Consumer Advisory Group and Southern Division of General Practice
Project Officer Don Tustin
Funded by Innovation Initiatives Program Department of Health South Australia
TABLE OF CONTENTS
EXECUTIVE SUMMARY.............................................................................1
Introduction ........................................................................................................................ 1 Aims and Objectives ......................................................................................................... 1 Methodology ...................................................................................................................... 1 Model of Collaborative Care ............................................................................................ 2 Implementation .................................................................................................................. 2 Evaluation of Partnership Process .................................................................................. 2 Evaluation of Six Dimensions of Care............................................................................. 3 Achievements .................................................................................................................... 3 Innovation .......................................................................................................................... 4 Key Recommendations .................................................................................................... 4
RECOMMENDATIONS ...............................................................................5
Model.................................................................................................................................. 5 Training .............................................................................................................................. 5 Risk Management ............................................................................................................. 5 Clinical Indicators .............................................................................................................. 6 Key Performance Indicators............................................................................................. 6 Consultancy-liaison Service ............................................................................................. 6 Carer Involvement............................................................................................................. 6 Further Funding................................................................................................................. 6
ACKNOWLEDGMENTS..............................................................................7 BACKGROUND...........................................................................................8
Models of Practice ............................................................................................................ 8 Groups of Consumers ...................................................................................................... 9 Need for a New System of Community Care ................................................................. 9 Demographics of Noarlunga .......................................................................................... 10 Mental Health Service System in Noarlunga................................................................ 10 Early General Practitioner Perspectives ....................................................................... 11 Access to Specialist Mental Health Service ................................................................. 11 Referral Pathways........................................................................................................... 13 Numbers of Consumers with General Practitioners .................................................... 13 Consumer Perspectives ................................................................................................. 13 Carer Perspectives ......................................................................................................... 14 Physical Health Issues ................................................................................................... 14 Literature on Collaborative Models of Care .................................................................. 15 Conclusion ....................................................................................................................... 16 Differences in Attitude and Culture................................................................................ 16 Staff Issues ...................................................................................................................... 17
ACTION PROCESSES: STAKEHOLDER DISCUSSION AROUND PRINCIPLES AND PHILOSOPHY............................................................18

Plan To Produce Sustainable Change.......................................................................... 18 Identify Attitudinal and Cultural Issues .......................................................................... 19 Agreed Philosophy of Care ............................................................................................ 29 An Agreed Philosophy of Care ...................................................................................... 30
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Identifying a New Model of Care ................................................................................... 30 Recommending a Clinical Communication System ..................................................... 32 Identifying Good Clinical Practices................................................................................ 33 Implementing Change .................................................................................................... 33 Evaluate Change............................................................................................................. 36 Input Measures................................................................................................................ 37 Compliance with Standards ........................................................................................... 37 Measures of Clinical Symptoms .................................................................................... 37 Clinical Indicator Measures ............................................................................................ 38 Sentinel Adverse Events ................................................................................................ 38 Key Performance Measures .......................................................................................... 38 Quality Control Methods in Community Mental Health ............................................... 38 Dissemination of Information ......................................................................................... 39
PROJECT FRAMEWORK.........................................................................40
Staffing ............................................................................................................................. 40 Governance ..................................................................................................................... 40 Role of the Advisory Group ............................................................................................ 41 Terms of Reference ........................................................................................................ 41 Evaluation Strategy......................................................................................................... 43 Changes to Goals ........................................................................................................... 43 Timetable ......................................................................................................................... 44 Overall Cost of Project.................................................................................................... 44
IMPLEMENTATION OF PROJECT ..........................................................45

Cycle 1- Clozapine .......................................................................................................... 45 Cycle 2 Consumers With Chronic Illness .................................................................. 51
EVALUATION STRATEGY .......................................................................66

Overview of Quality Assurance Measures.................................................................... 66 Dimensions of Care ........................................................................................................ 66 Partnership Processes ................................................................................................... 66 Experimental Design....................................................................................................... 69 Data on Topics Evaluated .............................................................................................. 69
QUALITATIVE REPORTS.........................................................................87
Ability to Provide each Form of Service ........................................................................ 87 Training for Sustainability ............................................................................................... 87 Risk Management Analyses .......................................................................................... 88
ACHIEVEMENTS OF THE PROJECT......................................................90

Goal 1 To improve integration .................................................................................... 90 Goal 2 Sustainability of Changes ............................................................................... 90 Goal 3 Improve Communication ................................................................................. 91 Goal 4 Extend Partnership to Other Agencies .......................................................... 91 Outcomes......................................................................................................................... 91 Informed Risk Management ........................................................................................... 91 What Worked Well .......................................................................................................... 92 Future Tasks.................................................................................................................... 92
REFERENCES ..........................................................................................93
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APPENDICES .............................................................................................1
1. 2. 3. 4. 5. 6. 7. 8. Concepts for Self Management of Mental Illness ......................................................I Agreed Strengths of Partners ................................................................................... III Multi-disciplinary Joint Care Plan Format................................................................ VI Protocol For Preparing Joint Care Plans .............................................................. VIII Joint Care Plans for Staff Training ............................................................................ X Audit for Written Communication with General Practitioner ............................... XVI Summary of relevant Medicare EPC Funding Items .......................................... XVII Revised questionnaires used for evaluation ........................................................ XIX
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COLLABORATIVE CARE IN MENTAL HEALTH IN NOARLUNGA EXECUTIVE SUMMARY

Introduction The Evaluating Collaborative Care in Mental Health (ECCMH) project was funded following expressions of concern by the Noarlunga Mental Health Consumer Advisory Group about a plan by one community mental health team in the Noarlunga Division of Mental Health to change its method of service delivery. The plan to commence a partnership with local General Practitioners was viewed by consumers as being likely to reduce the quality of services. Demand for community mental health services had been increasing due both to population expansion in the southern suburbs and to greater public awareness of mental health issues. The consumer group wanted an assurance that quality of their care would be maintained when care was transferred to their general practitioner. General practitioner groups responded by asking for a new system for providing community mental health care based on a genuine partnership. A collaborative partnership was formed between the Southern Division of General Practice, Consumers and Noarlunga Mental Health Services to seek funding for a project to develop a new model of care that was responsive to concerns of both consumers and General Practitioners. A submission for innovation funding from the Department of Human Services was successful. Aims and Objectives The project aimed to plan, implement and evaluate a new model of community care based on a partnership between community mental health services, General Practitioners, and other parties. The project also aimed to develop or identify measures that can be used to evaluate the new form of service delivery and that can be used in an ongoing quality assurance process. The project aimed to extend the reflective practice that was occurring in the mental health service to include all partners to change practice and to build a quality framework. Methodology Three original partners participated in the steering group that oversaw the project (Noarlunga Division of Mental Health, Southern Division of General Practice, and the Southern Region Consumer Advisory Group), together with a carer representative and a quality management professional. The project used a participatory action research approach to develop a new model of collaborative care for the Noarlunga region of Adelaide. The project used a health services improvement framework and incorporated tools available to General Practitioners through the Medicare funded Enhanced Primary Care items to support joint care planning.
COLLABORATIVE CARE IN MENTAL HEALTH IN NOARLUNGA

The project implemented two cycles. In cycle one the project defined partnership roles between the mental health service and General Practitioners by focusing on consumers who received Clozapine, an antipsychotic medication that requires close monitoring based on an established protocol. The approach was modified and extended in cycle two to consumers who have a significant and enduring mental illness with associated disability where there is ongoing potential for relapse, and where there were perceived barriers to transferring care to a general practitioner. Model of Collaborative Care The project developed a new model of collaborative care based on four phases of care to replace a traditional model involving two phases of care. The new model aimed to provide improved continuity of care, to ensure that both physical health and mental health issues are addressed, and to provide an ongoing emphasis on recovery and rehabilitation. Phases of care are designed to suit consumers at different stages of recovery from their illness. The model of collaborative care is based on strengths of partners that were identified both by the project steering group and in the literature leading to defined complementary roles for each stakeholder. Two new phases of care were introduced that involve joint work between mental health staff and general practitioners. The four phases of care in usual sequence are: Specialist care, where mental health treatment is provided by the specialist mental health service Shared care, where both the general practitioner and mental health service have clear roles that are defined in a joint care plan Consultancy, where the general practitioner is the primary health professional and is able readily to access advice and support from the mental health service General Practitioner care, where care of the client is transferred to the general practitioner.
The two new phases of care are shared care and consultancy. Implementation The new model of care was implemented with 60 consumers registered with community mental health services. Consumers selected had severe and enduring mental illness, and there was a perceived barrier to discharge from the mental health service. Barriers were a high potential for relapse, existence of legal orders covering treatment or finances, use of disability support services, and dependence on the mental health system. Consumers and their general practitioners were invited to participate in the collaborative arrangement that included evaluation. Evaluation of Partnership Process The project team developed questionnaires that were completed by five stakeholder groups to assess the quality of partnership processes. An experienced independent evaluator managed this evaluation with assistance from trained consumer and carer
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interviewers. The evaluation found that all stakeholders gave positive reports on most of the key aspects of the new partnership model. Evaluation of Six Dimensions of Care The project was also evaluated using measures of six dimensions of quality of care. Outcomes of the evaluation showed the following. 1. Equity of access improved as the new model of service delivery supported a 40% increase in number of consumers registered in the program. Aboriginal consumers gave similar ratings to quality of care as did other consumers. Appropriateness of care received positive ratings from all stakeholder groups. Over 50% of consumers received joint care from both their general practitioner and mental health service. Consumer participation was assessed from the proportion of consumers who signed joint care plans, showing a low participation rate. Effectiveness of service was assessed by use of other mental health services, showing moderate use of other services. Efficiency of service was assessed from the progression of consumers through phases of care, and from numbers of clinical contacts in each phase of care. There are no benchmarks for comparison using these measures. Safety of service delivery was assessed from reported sentinel events, with high levels of safety being achieved.
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3. 4. 5.
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All key performance measures have the potential to be used in a continuous quality assurance process. Achievements The project implemented a new form of collaborative care between General Practitioners and mental health key workers for consumers with moderately complex needs. The new model achieved outcomes with each goal of the project as it provides:
Improved integration by defining four phases of care for clients, allowing an orderly progression that makes best use of the skills of general practitioners and mental health services. Is sustainable as general practitioners use EPC items to reimburse their participation. The project based collaboration on identified strengths of each participant. Improved communication by using joint care plans to record the contribution of each participant. Extended the partnership by including non-government agencies that provide disability support in the partnership. Aboriginal clients participated in the project and gave positive ratings in the evaluation.

Innovation The project is innovative in several ways. 1. It introduced a new conceptual model of care for community mental health consumers that provide greater continuity of care by replacing a system based on two phases of care with a partnership model based on four phases of care. The new model of collaborative care facilitated a change in the system for delivering community services, as two new phases of care require joint work between General Practitioners and mental health services where both parties work simultaneously with consumers. Coordination of care was achieved primarily using a joint care plan. Preparation of joint care plans was funded using a Medicare Enhanced Primary Care item that has been introduced by the Commonwealth Government to support General Practitioners to work in partnership with other services. The collaborative model of care is available to any general practitioner who wishes to participate, and has a potential to be extended to further groups of consumers. The project has established that use of non-medical mental health practitioners is an option for providing increased assistance for General Practitioners. The new model of care ensures that both mental health and physical health issues are addressed in a coordinated manner. Disability support services participated in the model of collaborative care.
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3.
4. 5. 6.
Key Recommendations Key recommendations of the project are to: Use the collaborative model based on four phases of care to provide an orderly progression for clients as they recover. Provide ongoing training for all participants in collaborative care to promote sustainability. Adopt new approaches for risk management including a new system for monitoring side effects of medication, and use of aggregated data to assess risk factors. Develop further models of collaborative care for other client groups, especially consultancyliaison services for clients who are reasonably independent but who require periodic early intervention to prevent relapse.
COLLABORATIVE CARE IN MENTAL HEALTH IN NOARLUNGA RECOMMENDATIONS

That the Division of Mental Health of Noarlunga Health Services in partnership with the Southern Division of General Practice and Noarlunga Consumer Advisory Group continue to implement the work that has been commenced in this project by further developing the following issues. Model Continue to use the model of collaborative care based on phases of care to promote partnership arrangements with General Practitioners Invite staff of the Shared Care program to further refine operational definitions of phases of care based on information in this report, to further increase confidence in using each phase of care Further develop attitudes towards client-care and practices that are appropriate in each phase of care, to promote consumer independence and confidence, to clarify respective responsibilities, and to clarify appropriate risk-attitudes and duty of care in each phase of care Endorse use of joint care plans as the primary method of communication with General Practitioners in collaborative care arrangements Routinely provide General Practitioners with clinical information identified in the Melbourne CLIPP program when transferring care to General Practitioners State an expected frequency of contact with consumers in each phase of care based on information provided in this report.
Training Use materials outlined in this report to form the basis of ongoing training for both mental health staff and General Practitioners to promote the sustainability of initiatives in collaborative care, where training covers attitudes and practices, values and philosophy of care. Provide ongoing training to promote those skills that are required for collaborative work between mental health workers and General Practitioners.
Risk Management Adopt the clinical monitoring system recommended in the Mount Sinai conference for clients who are prescribed anti-psychotic medications to detect side effects, both within the mental health service and for General Practitioners. Further explore appropriate approaches towards clinical risk management in collaborative care arrangements using aggregated data for consumers in programs

Clinical Indicators Identify clinical indicators to report to quality systems that monitor good clinical practice in collaborative care and that can be audited at the level of individual clients and individual clinicians Adopt as clinical indicators: existence of joint care plans, consumer signatures on care plans, and recording early warning signs of relapse in care plans Adopt rate of presentation to emergency departments as a clinical indicator
Key Performance Indicators Identify key performance indicators to be reported regularly to senior management, such as aggregate rate of use of inpatient mental health services for a program, and identify benchmarks for the Shared Care program
Consultancy-liaison Service Clarify good clinical practice in having non-medical mental health clinicians provide a consultancy-liaison service to General Practitioners for clients who are not currently registered with the service and are not in a state of crisis; where the service is responsive to requests by General Practitioners, provides brief early intervention to clients as required, and provides advisory feedback to General Practitioners about how they might continue to manage presenting issues.
Carer Involvement Further investigate issues around the satisfaction of carers with service delivery
Further Funding Seek opportunities for further funding to continue the partnership work
COLLABORATIVE CARE IN MENTAL HEALTH IN NOARLUNGA ACKNOWLEDGMENTS

The success of this project is an outcome of efforts by many people from the three organisations that maintained a strong collaborative effort during the course of the project and that dedicated staff time to pursue the project objectives. Trevor Parry, Coralie Haynes and others on the Noarlunga Consumer Advisory Group displayed the wisdom to request funds for an ambitious project, and then spoke confidently from a consumer perspective when issues were raised. Rosalie Atkinson conscientiously represented views of carers and raised carer concerns during the progress of the project. Alf Martin of the Southern Division of General Practice very ably presented issues that the body of General Practitioners wanted addressed. Dr Bronwyn Veale gave advice when especially complex matters were being discussed. As members of the team, both Dr Peter Birdsey and Dr George Vlahos gave valuable opinions about what was workable for a busy general practitioner. Dr Meg Huppatz advised on very practical topics relating to accessing General Practitioners and remuneration issues. The key workers in the Shared Care program committed themselves from the beginning to providing clinical care in a project where the work is complex and guidelines were limited. These courageous people are Ann Todd-Egglestone, Barb McAlpine, Rob May, Deb Laverty and Cindy Davies. Jacqueline Murray took a lead role in implementing liaison with General Practitioners for consumers receiving Clozapine in cycle 1 of the project. Pam Marnie, Nicola Tomlinson and Ruth Lange joined the Shared Care staff in backfill positions and continued initiatives that had been commenced by their colleagues. Dr Priscilla Rathjen supported the project by providing educational feedback for General Practitioners as well as providing psychiatry services for the consumers. Theresa Francis provided important input about perspectives of Aboriginal consumers. Jamie Ryan joined as team leader when the service was re-organized. The project received ongoing support from both directors of the Mental Health Division (Liz Prowse and Dr Marcia Fogarty), and from the Director of the Division of General Practice (Deb Dutton), including during times when the project ventured onto new ground. The project received regular feedback from Jen Kay about how to apply quality assurance frameworks. Rebecca Horgan provided advice on privacy topics. David Rose conducted the independent evaluation. People who assisted the project during the early stages include John Brayley who saw the need for the project, Heather Petty and Deb Wildgoose who gave valuable feedback about how to organize a complex project, Carlene Wilson and Julie Syrette from CSIRO who gave advice about evaluation, and Mark Shove who was the first project officer. The project team is especially grateful to the member who took over catering arrangements to provide sustenance for the evening meetings.
COLLABORATIVE CARE IN MENTAL HEALTH IN NOARLUNGA BACKGROUND

A project originally named Evaluating Collaborative Care in Mental Health (ECCMH) was funded in 2001 by the Department of Human Services DHS as a new initiative project after a consumer group questioned a plan by one community mental health team in Noarlunga to change its method of delivering services so as to place a greater emphasis on the development of partnerships with primary health professionals as proposed in the Second National Mental Health Plan. The mental health team in Noarlunga planned to work more closely with General Practitioners involving long-term consumers who received specialist mental health services. The proposed change occurred at a time when community services were experiencing increasing demands due to an increase in population in the local area and an increasing public awareness of mental health issues. The consumer group expressed concern that the quality of services for existing consumers might be reduced as part of the attempt to provide services for increasing numbers of consumers. Representatives of the Southern Division of General Practice expressed general support for the proposed change in service delivery, while identifying a range of issues that required attention and improvement. The Division of General Practice considered that current methods of communication between community mental health services and General Practitioners were not adequate to support the type of partnership that was envisaged. During the course of the ECCMH project, the Mental Health Unit held a workshop on mental health rehabilitation and recovery that generated new philosophies about how to support consumers with chronic and enduring mental illnesses (Swan, 2003), and this thinking informed the project. Models of Practice The Noarlunga community mental health team in 1996 emphasised provision of services using a clinical case management model. By 2000 mental health staff in Noarlunga were questioning whether case management was the most effective method of service delivery in the Noarlunga context where there was a high demand for brief services. Literature also questioned the effectiveness of case management models (Mueser, Bond, & Drake, 1997), with one study (Marshall et al., 1996) finding that some forms of case management increase rather than reduce demand for inpatient beds. In 2000 the Noarlunga community mental health team decided to restructure their work, including working more closely with General Practitioners for consumers who had long term needs. Adopting a partnership approach to care with General Practitioners represented a move away from the clinical case management approach that had been endorsed in the South Australian DHS Guidelines for Service Provision that set up Continuing Care, Clinic and Consultancy (CCCC) teams in 1996.

In the clinical case management model developed by Kanter (1989), referred consumers are allocated to a non-medical professional key-worker who becomes responsible for coordinating service delivery for the consumer using resources both from the mental health team and from relevant community services. A treating team was established that usually comprises the key worker and a doctor from the clinic and clinical information was confidential to this treating team. The key worker had roles of educating consumers about their illness and effective interventions, educating carers to assist in a recovery process, assisting consumers to deal with environmental stressors that precipitate episodes of illness, and assisting with disabilities that arise due to the illness (Mueser, Bond & Drake, 1997). Quality of service delivery is maintained using three main mechanisms; an initial holistic assessment, having a treating team, and multi-disciplinary clinical reviews that receive input from clinicians in addition to members of the treating team. In a partnership system involving General Practitioners, there is uncertainty both about how care will be coordinated, and about what roles each service provider might adopt. General practitioner representatives sought a new model of care where non-medical mental health professionals became responsive to General Practitioners by providing opinion and advice to General Practitioners, a role that does not appear to be covered in the university training of disciplines employed in community mental health (mental health nursing, social work, clinical psychology, and occupational therapy). Groups of Consumers The 1996 service guidelines indicate that CCCC teams were set up to support a heterogeneous mix of consumers. Guiding principles for CCCC teams were to provide early intervention, to aim for recovery from illness, to promote consumer empowerment and self-determination by supporting consumers to make informed choices, and to provide continuity of care. In 2001 the Noarlunga CCCC team distinguished two groups of consumers, one group who recovered reasonably well within about 6 months, and a second group who showed more prolonged signs of disability with chronic and relapsing illness. The Noarlunga CCCCT changed its name to Community Care Team CCT so that not all consumers were promised continuing care by the team. The CCT began to provide services through three specialized programs called Early Psychosis, Brief Intervention, and Maintenance to address issues raised by groups of consumers that are prevalent in the Noarlunga area. This change involved briefer episodes of care, and transferring care to General Practitioners following recovery. In time the Maintenance program was called Shared Care to reflect the partnership with General Practitioners. Need for a New System of Community Care It became clear that a new system of care in community mental health was required that was based on a partnership approach where the key partners were mental health workers, General Practitioners, carers and consumers. The new system of community mental health care needed to be clearly articulated, to be supported by stakeholders, to be open to ongoing evaluation, and to be capable of being extended to other relevant service providers. A partnership group approached DHS asking for funds to achieve these objectives.

Demographics of Noarlunga The Social Atlas produced by the City of Onkaparinga is based on the 1996 census and reported that the Noarlunga health region covered 518 square kilometers and had a population of 146,000. The population was growing due to residential expansion, reaching 160,000 in 2001. The Social Atlas showed that in comparison to the whole of Adelaide city, there was a higher proportion of people aged under 19 years (29.6%), and a lower proportion of people aged over 60 years (14.2%). The region was described as being a mortgage belt as many householders were purchasing their own homes, with 7.5% of houses being owned by the South Australian Housing Trust. Of households, 43% comprised couples with dependent children, and 9.9% comprised one-parent families on a low income. Overall the income profile was similar to that of the whole of Adelaide. The level of unemployment was 6.9% in September 2002. Onkaparinga had a high proportion of people who were dependent on social security payments for their income, being one third of the population aged over 15 years. Of the population, 27% were born overseas, but only 0.5% did not speak English. 0.7% of the population was Aboriginal. Mental Health Service System in Noarlunga A listing of General Practitioners in the Onkaparinga region in August 1998 showed that 156 General Practitioners employed in 54 practices supported the region. Mental health services are managed by Noarlunga Health Services and are provided through an emergency department in the hospital, an inpatient ward with 20 beds, and by two community mental health teams that serve both Onkaparinga Council and three adjacent suburbs in the Marion Council area. In 2001 Noarlunga community mental health services reorganized themselves to provide services through five programs that operated from Adaire Clinic and that focused on specific groups of consumers who were prevalent in the region. The community mental health programs and consumer groups are: Noarlunga Emergency Mental Health Services NEMHS that provides 7 day per week management of local crisis situations for up to 3 weeks Brief Intervention program that provides short term early intervention for adults with mental illnesses for about 6 months Early Psychosis program to deal with young adults aged from 18 to 30 years with a first presentation of a psychotic disorder for 1-2 years Shared Care program to provide ongoing support for adults with a chronic mental illness who are currently reasonably stable, with support often continuing for several years Mobile Assertive Care to provide 7 day per week treatment for adults with very complex needs and considerable instability, often for 2-3 years.
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The Shared Care program that became the focus of this project was established to support consumers who had already received recovery-oriented services from other parts of the mental health system, but where consumers had not recovered sufficiently to be discharged so there was a need to continue interventions that had been commenced so as to consolidate gains over a period of many months. Many consumers in this program received ongoing support from a relative who acted as a carer. Community mental health staff saw that a system of collaborative care with General Practitioners would allow the care of more settled consumers to be transferred to their General Practitioners, permitting the resources of the mental health service to be concentrated more on people who require a briefer and more specialized service enabling these people to regain their capacity to lead an independent lifestyle. Early General Practitioner Perspectives A Liaison Officer was appointed by the Southern Division of General Practice to liaise with mental health services in 1998, commencing discussion about joint work. General Practitioner representatives in 2000 noted that a number of mental health consumers with chronic and relapsing conditions had recently been discharged to their care. An analysis of CCT discharges showed that the team had discharged 342 consumers to the care of their General Practitioners in the two years from 1996 to 1998. These consumers were discharged to enable the team to pick up new referrals that were being received at a rate of 20 per month. In 1998, General Practitioners noted that consumers were being discharged from the mental health service at the same time as management of medication was transferred to the General Practitioners. General Practitioners asked for early transfer of medication management to them, and asked for key workers to continue to provide ongoing support so as to provide greater continuity of care and support for the general practitioner. General Practitioners expressed confidence that they were able to manage consumers with chronic mental illness conditions, just as they manage people with other chronic conditions, provided they receive appropriate supports from specialist mental health services. Access to Specialist Mental Health Service In 1999-2000 a psychiatrist from Adaire Clinic made regular fortnightly visits to one general practice that supported a number of mental health consumers, providing a psychiatry-liaison service to this practice. The visits increased the confidence of these General Practitioners who obtained new ideas about management of consumers and continued to treat consumers whom they would previously have referred to mental health services. In 2000 General Practitioners asked for improved access to non-medical members of the community mental health service working with their consumers so that they could effectively become part of the ongoing treating team. The Southern Division of General Practice requested a review of the system of communication and referral between community teams and General Practitioners to enable them to make direct referrals.
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General Practitioners reported that the practice of providing a prompt discharge summary was satisfactory when consumers were discharged from the local inpatient ward. They asked for a different type of communication when care of clients was transferred by a community team. General Practitioners were aware of their ability to obtain assistance from: Private psychiatrists Emergency teams for consumers who are in a state of crisis
General Practitioners asked for early intervention assistance for consumers whose mental health appeared to be deteriorating but who had not yet reached a crisis state. They sought advice about how to manage the consumer, not only for direct services for consumers. General Practitioners asked for a brief liaison service, rather than for an holistic case-management service where the consumer is removed from the care of the General Practitioners for a long period of time. In 2000 General Practitioners commented that the current system in community mental health encouraged dichotomization, as consumers were either in or out of the mental health system, leaving inadequate support for those not in the system. The dichotomized system provided holistic care for some consumers while other consumers received little care from the mental health service. General Practitioners commented that the mental health service was both conservative about discharging consumers and reluctant to readmit previous consumers. General Practitioners commented that the case management approach introduced a spirit of possessiveness towards both consumers and skills, where clinicians spoke about your consumer, and where there was a territorial attitude towards skills that polarized areas of expertise by suggesting that General Practitioners were good at physical health, while mental health services had expertise in mental health care. General Practitioners asked for access to specialist opinions from mental health workers who have experience with particular consumers, noting that there are no objective physical tests to assist General Practitioners in making diagnoses and determinations equivalent to tests that are used to diagnose other diseases. General Practitioners asked for community mental health services to be responsive to their requests as occurs with other specialist services that deal with physical health issues. General Practitioners noted that as primary health care providers, they make referrals to other health specialists and receive feedback from specialists. However the reforms in 1996 that made ACIS the single point of entry to the mental health service had stopped the referral method where the general practitioner as primary health provider makes referrals to the more specialized service and receives feedback from the specialist service.
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Referral Pathways General Practitioners reported a perception that referral pathways of the time indicated that consumers need to be in a state of crisis before a referral will be accepted through the crisis entry point. They noted that a pattern of waiting until a crisis was imminent was not consistent with an early intervention approach for people who identified early signs of a relapse, and preferred to be able to contact the service that would provide ongoing care rather than going through an intermediary service. An analysis had been conducted of the source of referrals to the CCT in 1998. The analysis showed that the ACIS team made 40% of referrals, 35% were made by the local Morier inpatient unit, 13% by other inpatient units, and 12% by mental health services in other regions. An analysis was also made in 1998 of the location of contacts between mental health staff and consumers. The analysis found that 50% of contacts occurred in homes of consumers, 40% in the clinic, 7% in the inpatient ward, and 4% elsewhere. Few contacts occurred in offices of General Practitioners. Numbers of Consumers with General Practitioners In 2000 the Southern Division of General Practice provided a list of General Practitioners from a statewide survey who reported an interest in working in mental health. The list comprised 26 General Practitioners of whom 6 worked in the Noarlunga region. The list did not include all the names of doctors who were known to provide quality treatment for a number of mental health consumers. In 2000 an audit was conducted of the proportion of consumers registered with the Community Care Team who nominated a treating general practitioner. At that time there were 310 registered consumers and 227 nominated a treating general practitioner, showing that 74% of registered consumers had a treating general practitioner. Consumers nominated 127 different General Practitioners in the local area. An analysis of the number of consumers treated by each General Practitioner showed that 67% of General Practitioners cared for 1 registered consumer, 12.6% of General Practitioners for 2 consumers, 4% of General Practitioners for 3 consumers, 4% of General Practitioners for 4 consumers, and 3% of General Practitioners for 5 or more consumers. One general practitioner cared for 11 registered consumers. This information supported the premise that collaborative care arrangements should be offered to all General Practitioners in the region, rather than to target a few selected General Practitioners to treat many consumers. Consumer Perspectives Consumer representatives expressed concern about the changes that were proposed for service delivery. Consumers expressed feelings of being abandoned when they are discharged from mental health care, of losing contact with the service, and they worried that they would not receive the same quality of care from general practitioners as general practitioners might not know what to do and might treat them according to their diagnosis rather than according to their individual needs.
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Consumers sought a better working relationship between General Practitioners and mental health services that would be supportive of General Practitioners. Carer Perspectives Carer representatives expressed concern about proposals to discharge their relatives from mental health services. Carers reported obtaining a sense of security from knowing that their relative is registered with the mental health service, as registration provides a link that can be used if the relative either begins to relapse or if new treatments become available. Registration also reduces the sense of uncertainty about the future and reduces a feeling of burden that arises for carers who feel alone in caring for a relative. These feelings are heightened when the relative is withdrawn, has difficulty dealing with issues of daily living, is poor at keeping appointments and is unassertive about obtaining necessary services. Carers were happy for their relative to be on an inactive list or to receive a sleeper service. Carers generally expressed confidence in General Practitioners, but also sought better working relationships between General Practitioners and mental health services. Carers also wanted to be viewed as partners in the care process. Carers wanted to get away from a stop start process from reactive services where treatment is offered only when their relative is very ill and where support is withdrawn when the consumer shows signs of recovery and the General Practitioners becomes involved. Carers did not want their relative to be discharged and then have to be re-registered when there is a setback. Issues faced by carers of adults with severe mental illness have been described in literature (Leff & Vaughn, 1985; Kuipers & Bebington, 1988; Hatfield, 1983). Interventions that have gained positive reports from carers have been reported by Kavanagh (1992, 2001), Leff (1994) and Falloon, Boyd and McGill (1984). Literature indicates that carers of adults with a severe mental illness ask for support to reduce their anxiety about what might happen, to know that their relative is linked into supportive services, education to clarify reasonable expectations about what they might do, to be involved in care planning as being left out leaves carers feeling blamed, and to receive assistance for themselves especially during periods of crisis. The mental health team had begun to respond to carer perspectives by negotiating with the local Carer Support and Respite Service to provide monthly groups that were dedicated to supporting carers of adults with a mental illness. Physical Health Issues When the project commenced, literature was emerging from a study in Busselton in Western Australia showing a high level of physical health issues in mental health consumers (Coglan, Lawrence, Holman & Jablensky, 2001). The Busselton study noted that while mental health services purport to provide an holistic approach, issues of physical health were commonly over-looked in specialist mental health services. The study found that people with mental illness had excessive rates of diseases including Hepatitis C, infectious diseases, deficiency anaemias, digestive disorders, and Parkinsons disease. People with mental illness had excessive mortality rates from ischemic heart disease.
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The study also found that people with mental illness under-used physical health facilities. The study expressed a view that the case-management approach led to consumers losing usual links with mainstream services including physical health services, as only a small proportion of mental health consumers in the Busselton study had links to General Practitioners. These findings led to a conclusion that there was a need for closer liaison between mental health services and General Practitioners so that consumers could benefit from the physical health care provided by General Practitioners. The Royal College of General Practice in Australia (2000) issued guidelines that drew attention to the increased incidence of physical health conditions in people with schizophrenia and called for General Practitioners to offer preventive services for these consumers. The guidelines noted that people with schizophrenia have an increased incidence of high blood pressure, obesity, high blood cholesterol levels, diabetes, breast cancer and bowel cancer. The report noted that some of these conditions might be related to lifestyle issues such as smoking, low physical activity, poor diet, and use of alcohol and substances. It was noted that medications used to treat mental illness might contribute to the development of some physical health conditions. The College guidelines also noted that untreated physical illness might exacerbate mental illness. The ECCMH project accepted the conclusion of the Busselton study that there is a need for closer collaborative arrangements between General Practitioners and mental health services, and accepted that this collaboration is likely to produce benefits for the physical health of mental health consumers. Literature on Collaborative Models of Care International literature about collaborative care in mental health has been summarized in the Canadian Journal of Psychiatry (2002). Australian literature has been summarized by Keks et al. (1998), Penrose-Wall (1998) and PARC (2002). A contemporary New Zealand perspective is provided by Nelson et al (2003). The literature identifies five main models of collaborative care. In consultation-liaison in primary care psychiatry (CLIPP), some professionals from the mental health service attend selected General Practitioners practices to provide consultation and advice directly to General Practitioners (Meadows, 2001). In the UK it is common for a mental health nurse to be attached to selected general practices (Gournay & Brooking, 1994), whereas in Australia psychiatrists are more likely to spend time in general practices (Meadows, 2001). In shifted-outpatient arrangements, individual mental health professionals provide clinical services using the facilities of the general practice. In liaison attachments, a small group of mental health professionals are assigned to work from a primary care setting. In training placements, General Practitioners spend time in the facilities of the mental health service.
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In shared-care arrangements, there is a negotiated division of labour between the general practitioner and mental health professionals for individual consumers. Both General Practitioners and mental health staff provided agreed services for consumers based on both assessed needs of consumers and identified complementary skills of each professional.
The review in the Canadian Journal of Psychiatry (2002) noted that current models of shared care are criticised for being more relevant for acute care and for being less effective for consumers who have severe and persistent problems. Meadows (2002) reported that the CLIPP program in Melbourne offers both shared care and consultancy services. Consultancy is offered predominantly for high prevalence disorders such as neuroses, depression, adjustment disorder and substance abuse. The primary service offered in consultancy is advice to the General Practitioners about appropriate intervention. Shared care is sought by General Practitioners more for low prevalence disorders such as schizophrenia, bipolar disorder, schizoaffective disorder, brief psychosis, and delusional disorder. Conclusion The ECCMH Advisory Group decided to plan a new method of collaborative care that builds on the principles of shared care. It was agreed to plan a model of care that could be used by all General Practitioners in the region instead of focusing services on a few selected General Practitioners and that would involve all clinicians who work as key workers for consumers. It was agreed to develop a model of collaborative care that in time can be extended to most mental health consumers. Differences in Attitude and Culture Literature discussing collaborative care between General Practitioners and mental health services in Australia note that these services have developed separately and have adopted so many different practices as to have different cultures (Hickie, 1999; Holmwood et al., 2000; Keks et al. 1998). The literature identifies a number of issues where attitudinal differences need to be addressed before a successful partnership can be introduced. Key issues where there are attitudinal and cultural differences in practice include: Reimbursement and funding Confidentiality Ability of consumers to self manage their illness Views about recovery Risk attitudes Views about case management Role of family members Expected outcomes of case management Access to disability support Prevalence of conditions as being high or low
The ECCMH project decided to address underlying attitudinal issues to establish a firm foundation for the cooperative venture.
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Staff Issues There is literature about both psychiatrists (Meadows, 1998) and mental health nurses (Gournay & Brooking, 1994) providing liaison and consultancy services to General Practitioners. As noted above, General Practitioners in Noarlunga sought input from the Shared Care program where multi-disciplinary staff came from the disciplines of social work, mental health nursing, and paramedical aide. These staff had commenced an early form of shared care in 1998 for consumers who were stable and were seen by key workers primarily to monitor mental state and use of medication. There is an awareness that increasing expectations and workloads of community mental health staff introduced a potential for burnout in staff (Rafalowicz, 1997).
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COLLABORATIVE CARE IN MENTAL HEALTH IN NOARLUNGA ACTION PROCESSES: STAKEHOLDER DISCUSSION AROUND PRINCIPLES AND PHILOSOPHY
The project sought to encourage reflective practice amongst partners that was similar to the reflective practice that was occurring within the mental health service. The ECCMH project was asked to plan, implement, and evaluate change. The project was organized using a participatory action research paradigm that is based on cycles of activities where each cycle includes components of: Planning by incorporating ideas from three sources of information: literature, opinions of experienced clinicians, and information from outcome studies Implementing the new partnership process for one consumer group Evaluation by measuring both processes and outcomes to assess six dimensions of quality of health care, together with processes that are important in a successful partnership Refining concepts and commencing a further cycle with another consumer group
Major topics for planning involved: Attitudinal and cultural issues Good clinical practices
Change was implemented by: Clarifying change management strategies Clarifying risk management strategies Addressing staff issues Clarifying the capacity of General Practitioners to operate in new ways
Focusing on two processes carried out evaluation: Partnership processes Clinical activities using the framework Six dimension of quality
Plan To Produce Sustainable Change Two cycles were planned in the ECCMH project using a participatory action research paradigm. The first cycle focused on consumers who received the medication Clozapine. The second cycle focused on consumers who have a chronic mental illness with associated disability and where there is some barrier to transferring care to a general practitioner. The ECCMH project team identified key processes considered to underpin the success of a collaborative care partnership. Basic elements for the partnership model were introduced in the first cycle and learning from the first cycle was used to refine the model of partnership that was used in the second cycle. There was further learning from the second cycle.
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Identify Attitudinal and Cultural Issues The steering group of the ECCMH project addressed the following attitudinal issues that had a potential to impact on the project, and took the steps that are described. i Reimbursement and Funding for Service Provision Professionals in the mental health service and General Practitioners are employed and reimbursed on different bases, as mental health staff work on a salary while General Practitioners operate as small businesses where they are reimbursed on a fee-for-service basis using both Medicare items and charges to consumers. While state funded mental services do not charge consumers for services, General Practitioners may ask consumers to pay a gap fee. Consumers who are on a low income may be reluctant to receive care primarily from their general practitioner if they are required to pay for services they have previously received freely. It was recognised that General Practitioners will be unable to spend time in the planning and liaison activities that are required in collaborative work unless they are reimbursed for their time. The Commonwealth Government had introduced a range of new Enhanced Primary Care (EPC) items to reimburse General Practitioners for working collaboratively with other parts of the health service. One task of the ECCMH project was to encourage all parties to use suitable EPC items for mental health consumers. The ECCMH project used the following strategies to encourage use of EPC items: ii The project identified one item as most appropriate for reimbursement (item 720 for new care plans) The Southern Division of General Practice advised General Practitioners about the availability of EPC items Key workers were informed about EPC items (See appendix 7), and were in a position to pass on this information to General Practitioners
Confidentiality Holmwood (1998) identified confidentiality practices as one hindrance to the exchange of clinical information that is required in a collaborative approach. The Mental Health Act of South Australia (1993) section 34 has strong provisions to protect the confidentiality of consumer information. Carers commented that confidentiality principles are often cited to exclude them from receiving information they feel they need when caring for their relative.
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The ECCMH project addressed confidentiality principles in the following ways: Arranged for an expert presentation about privacy issues to the advisory group Followed requirements of the Code of Fair Information Practice issued by the Department of Human Services 2002. Prepared documentation for key workers to inform consumers and carers about the new form of collaborative service delivery where clinical information is shared with their general practitioner, and invited their participation. Supported involvement of carers as agreed by the consumer, especially when the consumer lived in the carers home. iii Ability of Consumers to Self Manage their Illness A key issue in the ECCMH project involves the ability of consumers with a chronic mental health condition to make their own decisions about their treatment and to self manage their illness. An attitude that mental health consumers are unable to learn to make their own decisions influences the role of treating clinicians and raises questions about how decisions are to be made especially when there is more than one service provider. A report of the National Mental Health Strategy by the Mental Health Council of Australia Enhancing relationships between health professionals and consumers and carers (2000) makes the following comments about attitudes of professionals: In general, the results showed that consumers and carers feel more strongly than professionals that they have rights to genuine input and participation around issues of treatment, care and decision making, and that they are given insufficient choice (page 17). Consumers and carers feel their experience and knowledge is not being acknowledged by health professionals, that is, treatment is not developed collaboratively (page 22) Consumers and carers feel there is still a lack of information about non medical treatments and a lack of choice is provided by health professionals (page 26)
Studies provide evidence that people with psychotic illnesses are able to learn to self manage their own illnesses (Fowler, Garety & Kuipers, 1995). The argument that people with a chronic mental health condition are often not capable of making decisions about their own treatment points to the fact that mental illness produces disordered thinking and so impacts directly on decision making skills. It is noted that disordered thinking may improve when the person takes medication. If a consumer takes medication as prescribed, then the person is considered to be compliant. On the other hand there is a risk that a client will experience a relapse if the client stops using medication where the clients cognitive abilities deteriorate to the point where the client becomes unable to make informed decisions. From this perspective, a person who wants to cease medication is considered as a poor decision-maker about their own treatment, as the person makes decisions that are not recommended by their therapist.
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Mental health legislation has been passed to address situations where consumers are unable to make effective decisions that enables mental health professionals to apply for legal orders that remove the right of consumers to make decisions in two areas of life, involving treatment of their mental health condition (through a community treatment order CTO) and about management of their finances (through an administration order). CTOs are time limited for a period of one year, reflecting a view that consumers can recover their decisionmaking capacities as they respond to treatment. CTOs provide consumers with a period of supervised treatment. One view is that the existence of mental health legislation imposes a duty of care on mental health professionals to protect consumers from the possibility of making faulty decisions such as ceasing medication and having a relapse, especially a relapse that is sufficiently severe as to require hospitalisation. The ECCMH steering group heard reports that people with a chronic mental illness want to cease medication for a range of reasons including: The person has improved considerably and believes they are cured, and does not recognise the preventive role of medication Adverse effects of the medication become more prominent than beneficial effects The person wants a trial of non-medication alternatives to manage their illness.
The ECCMH steering group recognized that a proportion of consumers with a chronic mental health condition are able to recover and to regain their capacity to make decisions about their treatment just as occurs with people who have a chronic physical illness. Mental health and physical health conditions have sufficient common features that it appears that methods of self-management used in physical illness can also be used by mental health consumers. During the time of the ECCMH project, Noarlunga Health Services hosted another project that promoted self-management of chronic conditions and this project informed the ECCMH project (Urukalo, 2002). The ECCMH project was also informed by a report by Marwick, Reece and Battersby (2002) conducted at Flinders University involving self-management of chronic physical diseases. This report found that ability of consumers to self manage their condition was a better predictor of number of hours required to support a consumer than either severity or complexity of the condition. They reported that key indicators of successful self management include agreement between the consumer and professional about how to describe the problem and the ability of consumers to communicate with their doctor about both beneficial and adverse effects of medication. The Marwick, Reece and Battersby study promoted a sense of optimism that the self-management approach can be used with mental health consumers. The ECCMH project was informed by a model of self-management of mental illness that is given in Appendix 1.
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iv Views about Recovery The ECCMH steering group spent time discussing the concept of recovery, informed by emerging literature (Anthony, 1993; OHagan, 2004; McGorry, 1992; van Hoof, van Weeghel, & Kroon, 2000). Three concepts of recovery were distinguished. One concept of recovery amounts to a cure as there is an absence of symptoms and the person returns to full normal functioning. A second view of recovery aims to protect ill consumers from social and environmental challenges of daily living until the person is considered able to deal with these stressors. A third concept of recovery that has been described by consumer representatives is more relevant for consumers with chronic illness (Copeland, 2002; Mead & Copeland, 2000; Rickwood, 2004; Swan, 2003; Synergy, 2004). In the third understanding of recovery, a person is said to have recovered if the person is able to lead a satisfactory lifestyle within limits that are set by the illness, based on a realistic acknowledgement of the impact of the illness. Recovery is not equivalent to absence of symptoms. The person accepts that symptoms interfere with functioning and lifestyle, but does not allow symptoms to dominate their lifestyle. The person looks for interventions that reduce the likelihood and severity of symptoms and episodes of illness. Consumers who articulate the third understanding of recovery do not aim to get well quickly and get on with life as usual or to return to normality, but instead they aim to find a new lifestyle that suits their own values rather than the values of a service system. These consumers want to evaluate services from their own perspective, rather than to be required to conform to an evaluation system that has built-in values, such as compliance with medication or maximization of potential or independence. Consumers who follow the third understanding of recovery distinguish interventions they experience as being supportive or non-supportive. Nonsupportive interventions by professionals include dire predictions about the consequences of not following the advice of professionals, such as You will go back to square one. Supportive interventions include acceptance when a person wants to learn about a wider range of interventions than medication. Mead and Copeland (2002) include as supportive interventions an opportunity to communicate with trusted people who provide emotional support and being allowed to move away from stressful situations. Consumers who follow the third understanding of recovery ask for the right to make their own decisions about treatment, saying that they grow from the experience of taking risks, even when they do things that others consider to be mistakes. These people do not want always to have to conform to ideas and limits that are imposed by others, as this approach promotes learned helplessness. These people want to learn techniques to self-manage their illness, even if this involves some risk and relapse. These people do not want to harm others, but they are willing to take some risks involving themselves.
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Consumers who speak about the third form of recovery ask for opportunities not restrictions, optimism not gloom, and having responsibility for success attributed to the individual rather than to the medication (Scotman, 2004). From the perspective of the third understanding of recovery, a person is said to have recovered when the person has skills to manage episodes of illness and is able to lead a lifestyle that is satisfactory to the consumer. A person who wants to prohibit the consumer from experiencing this form of recovery is described as over protective. The ECCMH project proceeded on the basis of the latter understanding of recovery. v Risk Attitudes and Right to Decide Different attitudes about risk issues have been discerned when mental health consumers want to make their own decisions about their treatment especially when consumer decisions differ from recommendations made by their doctor (McIvor, 1998; Brophy & McDermott, 2003; Centre for Addiction and Mental Health, 2003). The National Mental Health Report (2002) states, consumers and carers often feel they are given insufficient choice and participation in the care they receive, that it is difficult to talk to some professionals about problems, and that the attitudes of some professionals were stigmatising (page 135). The report Evaluation of the Second National Mental Health Plan (2003, pages 13 to 25) makes the following statements about consumer rights: consumers remain vulnerable to violation of their rights regarding consumer and carer involvement in individual treatment decisions, there is substantial need for improvement A commonly expressed view is that the mental health workforce itself perpetuates the stigma of mental illness
The Australian Health Ministers in the National Mental Health Plan 2003-2008 state as one objective Continue to ensure all States and territories have legislation and service provision that protects the rights of consumers and the community. The ECCMH steering group discussed the dilemmas that can arise if the principle of consumer competence to make final decisions about treatment is transferred from physical health to mental health issues. The principle of consumer competence indicates that a health consumer is able to make informed decisions about their own treatment regardless of the nature of the diagnosed illness. Implementing the principle of consumer competence introduces a possibility or a risk that a health consumer may make a decision to cease medication that will increase the likelihood of a relapse of illness. The risk of a relapse may be lower if the treating professional makes decisions about treatment, however this approach is viewed by consumers as being paternalistic. The ECCMH steering group discussed risk issues that arises with any chronic illness, including physical illnesses such as hypertension, diabetes and arthritis.
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The severity of a relapse of any of these illnesses may be such that the person requires hospitalization to recommence treatment. The ECCMH group discussed dilemmas that arise if a person with a mental illness also has physical illnesses that require treatment. There is a literature about the psychology of decision-making in situations where outcomes are uncertain or are risky as there is a possibility that negative outcomes or losses will occur (Gilovich, Griffen & Kahneman, 2002; Sternberg & Ben-Zeev, 2001; Fennema & Wakker, 1997). Research identifies distinctive riskattitudes or biases, distinguishing an attitude of avoiding risk called risk-aversion from an attitude of acceptance of risk called risk-acceptance. Research indicates that risk-attitude influences perceptions about risk situations. Attitude towards risk of relapse is one area where there is potential for differences of opinion to emerge between health professionals, if some health professionals adopt an attitude of risk-aversion while other health professionals adopt an attitude of risk-acceptance. Risk-attitude may in turn influence perceived duty of care. Health professionals with an attitude of risk-aversion may perceive that they have a very high duty-of-care to prevent relapse of an illness, and to prevent presentations to emergency services or admissions to hospital. In contrast, health professionals with an attitude of risk-acceptance may consider that their duty of care is to offer interventions that are reasonable according to the standards for managing other health conditions, while leaving the final decision to be made by the client who is affected by the decision. An attitude of risk-acceptance acknowledges that relapse may occur, especially during a period when a consumer is learning to manage a newly diagnosed illness. A health professional with an attitude of risk-acceptance may operate within a defined level of presentations to emergency services and admissions to hospital, and may not have an attitude of zero tolerance towards these occurrences. The question arose of how to establish a consistent attitude towards risk that can be accepted within both mental health services and general practice, two groups that have separate histories and practices. The ECCMH project needed to identify mechanisms to clarify risk-attitudes to guide intervention for consumers who were in the joint care of both service systems. In mental health, differences in professionals attitudes towards risk are related to the professionals perception of the ability of an individual consumer to make their own decisions, and this becomes expressed in terms of the professionals perceived duty-of-care (Jaworowski & Guneva, 2000). Consumers with a physical illness are viewed by both their general practitioner and specialist as being responsible for their own actions and decisions. The perceived duty-ofcare for a general practitioner who treats a person with a physical health disease is to assess the health condition, and to offer and provide services as recommended by a specialist and agreed by the consumer, leaving the consumer to have the final say about treatment. However if a consumer has a diagnosed mental illness, then some people perceive a higher duty-of-care where staff of a mental health service have a responsibility to be more assertive in providing follow-up for consumers who decline treatment that was recommended by the specialist. In this sense, the higher perceived duty-of-care is associated with a risk attitude that is more risk-averse. The risk-attitude that
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prevails may be the attitude of the treating professional rather than the attitude of the consumer.
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An attitude of risk-aversion is revealed in situations where there is a predictable possibility that a consumer will experience an adverse outcome. A professional with an attitude of risk-aversion will perceive themselves as being open to criticism of not having done enough to prevent the risk, so the professional will try to reduce criticism towards themselves as well as to try to minimize the impact of a possible adverse outcome for a consumer. Psychological literature shows that people with an attitude of risk-aversion over-estimate the likelihood of negative outcomes, have a lower threshold when classifying events as adverse, and magnify the predicted severity of outcomes (Tversky & Koehler, 1994). Attitudes of risk-aversion are maintained in cultures that are blame-oriented as there is an increased focus both on the occurrence of adverse events and on identifying the source of adverse events, rather than on emphasizing positive outcomes of intervention. If a mental health consumer experiences adverse outcomes, then risk-averse professionals may perceive themselves as being responsible for the actions of the consumer, if it is considered that the professional has both a duty-of-care to foresee adverse outcomes and the capacity to over-ride the ability of a consumer to make their own faulty decisions. Even provision of routine administrative feedback can be viewed by professionals with an attitude of risk-aversion as reflecting implied criticism, such as provision of information about presentations by clients to the Emergency Department of a hospital or rate of admission to an inpatient unit. Health professionals who have an attitude of risk-aversion face ongoing dilemmas as they are viewed by some consumers as being over-protective when the professional show discomfort when the consumer wants to make their own independent decisions, and the professional may receive mixed feedback from their colleagues with some colleagues focusing on the goal of client independence while other colleagues focus on clients unmet needs. The ECCMH project decided to address issues of risk attitude by including consumers whose right to make decisions had been restricted by the Guardianship Board by making the consumers subject to a CTO or to an administration order. vi Views about Case Management Views about case management were an important issue. One difficulty with the clinical case management model is that it can be defined so widely as to leave no limits to what a case manager is asked to do (Mueser, Bond, Drake & Resnick, 1998). Literature and policy documents distinguish assertive case management that is provided by teams that provides intensive input over 7 days of the week from standard case management that provides structured therapy and education from a five day per week team.
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Common roles of case managers are to assist consumers to deal with stresses of daily living that precipitate episodes of illness, to provide psycho-education about illness and effective methods for managing the illness, to provide intermittent individual psychotherapy, and to promote or maintain sufficient social integration as to avoid reliance on institutional living. Some models of case management have additional expectations. Case managers are often asked to address assessed needs of consumers. However literature has not identified any standard approach for assessing individual consumer needs (Mueser et al, 1998). Some models (National case management working group, 1997) define needs of consumers so broadly that mental health key workers feel responsible for addressing all needs of consumers including needs that have no association with the mental health of the consumer. Broad definitions leave workers feeling uncomfortable about discharging consumers if the consumer still has an unmet need. If staff within a service follow different definitions of the case management role, this produces controversy within the service where staff members who adopt a broad definition refer to staff members who adopt a narrow definition as being uncaring while those who adopt the narrow definition refer to staff members who adopt a broad definition as being over-involved. Caring can become defined by how much effort a staff member puts into assisting a consumer. There is concern that broad definitions may result in workers providing so much direct assistance to consumers that the help reduces self-sufficiency and creates dependence on the service (Mueser, et al, 1998). Even when a team endorses a model of case management, questions arise about fidelity with which all staff members implement the model or whether individual staff members claim a right as a professional to function in distinctive ways. Some models of case management emphasize the importance of the personal relationship that is formed between key-worker and consumer. These models encourage workers to maintain frequent contact with consumers on the basis that reducing contact might be viewed as unhelpful and may undermine the therapeutic relationship. Mueser et al (1998) note a need for research to identify characteristics of consumers and workers that are associated with maintenance of good mental health when intensity of service is reduced. vii Role of Family Members Models of case management reflect different views about roles of family members (Mueser et al, 1998). Some models have been developed for people who have no link with their family. Other models ask family members to adopt a role of carer by asking the relative to be informed both about the consumer and about the mental illness so that the relative is in a position of being able to pass relevant information on to the mental health service and to be able to participate in the therapy team especially by providing emotional support to the consumer (Burns, 1997; Kavanagh, 1991).
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viii Expected Outcomes of Case Management There is a literature about outcomes that can be expected from case management of community mental health consumers. Simmonds, Coid, Joseph, Marriott and Tyrer (2001) reviewed 65 studies and concluded that provision of case management is associated with greater acceptance of treatment, with fewer deaths by suicide and in suspicious circumstances, with increased satisfaction with care, and with shorter inpatient episodes. They reported no overall improvement in clinical symptoms or in social functioning. Mueser et al (1998) reviewed 75 studies and reported that case management maintains but does not improve social functioning or vocational outcomes, unless a specific and substantial program is devoted to these topics. Scales are now available that are designed to detect changes in mental state due to treatment of a mental health condition. Some scales have been endorsed for use in Australia as part of the National Outcomes and Casemix Collection (NOCC) approach and are now mandatory (Pirkis et al, 2005). NOCC scales include Health of the Nation Outcome Scales (HoNOS), Abbreviated Life Skills Profile (LSP-16), and Kessler K-10. The HoNOS scale has been shown to detect changes in symptoms during a period of hospital treatment for an acute episode of mental illness (Trauer, Callaly, & Hantz, 1999). While an early study reported improvement in sub-scales of HoNOS following 6 months of community casework (Sharma, Wilkinson & Fear, 1999), other studies have not found the same result (Pirkis et al, 2005). Some writers question whether HoNOS is suitable for detecting change produced by community mental health services (Bebbington, Brugha, Hill, Marsden & Window, 1999). ix Access to Disability Support At the commencement of the ECCMH project, some participants held a view that consumers needed to be registered with mental health services in order to be eligible for disability support that is provided by non-government agencies. This resulted in some consumers being registered primarily to receive disability support. During the project, it was clarified that General Practitioners could make referrals for disability support and that General Practitioners could adopt the role of case manager if they oversighted the disability support. x High and Low Prevalence Conditions One premise is that the most rational use of resources occurs when primary health care professionals treat common or high prevalence conditions, while specialized services treat more unusual or low prevalence conditions (Andrews, Peters & Teesson, 1994). In mental health, psychoses are identified as low prevalence conditions while anxiety and depression are identified as high prevalence conditions.
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General Practitioners noted that due to the increasing prevalence of all mental disorders, they are already being asked to provide follow-up treatment for low prevalence conditions such as psychoses. General Practitioners also noted that many of the high prevalence conditions were complex and they sought access to more specialist services for advice about management of individual cases. The ECCMH project decided not to make prevalence of conditions a major factor in planning a new form of service delivery, including diagnoses of both psychoses and depression in the project. RECOMMENDATION 1: That the Division of Mental Health introduce an ongoing staff training program that promotes the attitudes and values used in the collaborative care project. Agreed Philosophy of Care The ECCMH project addressed attitudinal issues by: i Clarifying key partners and encouraging ongoing communication about proposals from representatives of these partners Developing an agreed philosophy of care Collaboration based on identified strengths of partners to lead to complementary practices Identifying an agreed model of care Recommending an educational system of handover and a method of reimbursement for General Practitioners to participate in care planning Clarification of Partners The ECCMH project identified as partners for the first two cycles of the project those agencies that provide direct services and support to consumers in the target groups. This approach identified consumer representatives, carer representatives, General Practitioners and General Practitioners representatives, mental health staff and non-government agencies that provided disability support services. These groups were included in the evaluation of the project. Other agencies expressed an interest in participating in collaborative care exercises, including Drug and Alcohol Services, Family and Youth Services, and Intellectual Disability Services. These agencies were prioritised for later cycles. ii Collaboration Based on Identified Strengths The project team agreed to introduce a system of collaborative care that made the best use of acknowledged strengths of each partner. Literature was reviewed to assist in discussing strengths of each partner (Hickie et al. 2001a and 2001b; Meadows, 2000; I seru, 1997). The steering committee debated proposed strengths of each of the following potential partners until agreement was reached. Potential partners whose strengths were discussed are: consumers, General Practitioners, key workers, psychiatrists, carers,
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disability support services, and pharmacies. Agreed strengths of each partner are listed in Appendix 2. The project team then developed a model of collaborative care that utilised agreed strengths of each participant. An Agreed Philosophy of Care Literature was reviewed to identify issues where there was a potential for discrepant philosophies of care between general practice and mental health services. The ECCMH project team then developed an agreed philosophy of care for collaborative care based on the following principles: Intervention aims to promote consumer recovery and self-management of illness whenever possible Consumer competence to make decisions about their treatment is presumed, although this competence may vary Consumers make decisions about which intervention is in their own best interest, selecting from options recommended by clinicians Clinicians provide information about recommended interventions that covers both expected benefits and likely significant side-effects The value of both medical and non-medical interventions are recognised Intervention promotes use of the primary care system and aims to reduce reliance on specialist services Specialist mental health support is available to primary health care professionals who provide ongoing care for individual consumers
Identifying a New Model of Care The project identified a new model of care that was relevant to the changing needs of consumers as they achieved different levels of recovery, made use of identified strengths of stakeholders including consumers, and made use of support provided by carers. The new model of care provides greater continuity of care as it is based on the concept of consumers moving through four phases of care, instead of changing abruptly from being a registered consumer to being discharged to care of a general practitioner.
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A new model of collaborative care was developed comprising four phases of care to provide an orderly transition between care by mental health services and care by the general practitioner, according to the stage of recovery of the consumer. Much of the work of the project involved developing, implementing and evaluating the two new phases of care; shared care and consultancy. The concept of a treating team was expanded so as to include the consumers nominated general practitioner in all four phases of care. Confidential clinical information was shared within the treating team that now included the general practitioner. Consumers were asked to participate in formulating a joint care plan involving members of the treating team and to sign the individual care plan. The four phases in the collaborative care model in usual sequence are: Specialist care Shared care Consultancy General practitioner care
It was recognized that while most clients recover and progress through the phases of care, some clients regress. Basic definitions of each phase of care were introduced by stating roles of each participant for each phase of care. Initial definitions did not include precise indicators to identify consumers who are suited to each phase of care. The initial definitions are given in Table 1. The column Role of consumer was developed on the basis of feedback provided by a focus group of consumers.
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Table 1. Phases of Care
Phase
1. Specialist Care 2. Shared Care
Role of Community Mental Health Service

MHS assesses and provides mental health services directly to the consumer. MHS works jointly in a partnership, with each professional providing agreed services MHS provides input to the general practitioner as requested.
Role of General Practitioner

General practitioner is informed about mental health issues. General practitioner provides defined care for a mental health condition as agreed in a care plan. General Practitioner is the primary therapist for all health issues. General practitioner is able to contact identified MHS staff. General practitioner is the ongoing primary health care professional for both physical and mental health conditions.
Role of Consumer
Consumer seeks specialist assistance Consumer participates in forming the care plan and stating desired outcomes. Consumer attends appointments. Consumer sees the general practitioner regularly for all health needs.
3. Consultancy
4. General Practitioner Care
Consumer is discharged from MHS care.
Consumer sees the general practitioner for all health needs.
RECOMMENDATION 2: Continue to use the model of collaborative care based on phases of care to promote partnership arrangements with General Practitioners. Recommending a Clinical Communication System The ECCMH project recommended that routine clinical communication between the consumer, general practitioner and mental health worker be based on a modified version of the multi-disciplinary care plan as shown in Appendix 3. This form is called a joint care plan. The ECCMH project recommended that General Practitioners be reimbursed for participating in preparing a joint care plan by claiming EPC item 720. The ECCMH project recommended that key workers take a lead role in assisting General Practitioners to prepare joint care plans by following the protocol that is given in Appendix 4.
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Identifying Good Clinical Practices The ECCMH project operated on the premise that community mental health staff were familiar with best clinical practice to treat and to maintain improvements in mental health of people who have a chronic mental illness. The purpose of the project was to ensure that information about best clinical practice was available to General Practitioners so as to enhance the knowledge, skills and confidence of General Practitioners. A policy paper Future directions for better integration between mental health services and general practice and other primary care providers in South Australia (2001) produced by a Services Delivery Models Working Group outlined a vision for new ways of operating. This document suggested that collaborative care would be assisted if General Practitioners had access to clinical guidelines about treatment of conditions. Mazza and Russell (2000) examined the role of Clinical Practice Guidelines in supporting collaborative care in mental health, and found that General Practitioners favoured use of clinical practice guidelines in certain situations that were listed. Penrose-Wall and Harris (2000) also discussed the benefits of having agreed clinical guidelines to support collaborative work. The ECCMH project team considered that the task of preparing and updating clinical practice guidelines was beyond the scope of the project and was best carried out at a national level from a university base. The ECCMH team considered that these guidelines would be most accessible to General Practitioners if provided electronically. Implementing Change The ECCMH project was asked to produce change in two systems that deliver mental health services, general practice and community mental health, not simply to add a component to current systems. The two systems had a history over many decades of operating separately and of following different practices. The project was asked to report key intervention strategies that were considered to have been effective in producing change. The literature indicates that if collaborative care programs are to be effective and sustainable, then complementary changes are required both in the local mental health service and with General Practitioners (Hickie, 1999). The project team agreed that the change process needed to address the following issues: Education about the new model of care Training to involve mutual learning Referral of contentious issues to the Advisory Group Working at a pace that is manageable for all parties and is safe Identifying topics for ongoing training for General Practitioners and mental health staff Monitoring demands on staff
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Commencing change involving one staff member and then offering change opportunities to increasing numbers of staff Monitoring risk issues Reviewing size of caseloads
Planning for each key intervention strategy is outlined below. i Education About the New Model of Care Key workers employed in the Shared Care program at the commencement of the collaborative care project participated in discussions that clarified the new model of collaborative care. The new model of care was written up. Key workers were asked to nominate consumers who were suitable to participate in the collaborative care project based on established criteria and to educate these consumers about the new form of care using Table 1. General Practitioners who were nominated by selected consumers received a letter inviting them to participate in the collaborative care project. The letter outlined the new model of collaborative care. ii Training Involving Mutual Learning There is a literature about training for professionals who participate in collaborative care (Meadows, 2000; I seru, 1997; Weir and Penrose-Wall, 1999; Garton, 1999; Hazelton, 1999; Harries, 1999; Kosky, Rosen & Phillips, 1999). The ECCMH project established a Joint Training Working Group comprising representatives of stakeholder groups to identify topics where training was required for key workers and General Practitioners, and to organise this training. iii Contentious Issues It was apparent that the collaborative care project involved substantial change in practice for both mental health staff and General Practitioners, and it was anticipated that some changes to practice would evoke attitudinal issues. The project officer and other members of the steering group identified topics that were considered to be more contentious, based on literature and other sources. Potentially contentious issues were brought to the steering group for discussion and resolution. Members of the steering group were aware that they represented wider groups and were encouraged to approach their groups for advice if necessary. The project had funds to organise focus groups on specific topics and this avenue was used to address some topics. iv Pace of Progress Pace of progress was planned to be steady and safe allowing all parties to keep up, even if the pace proved to be slow by some standards. Feedback from all parties was encouraged at every phase. The project commenced with consumers whose needs were moderately complex, being consumers in the Shared Care program.
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v Topics for Ongoing Training The ECCMH project established a working group to monitor topics where ongoing training is required for both General Practitioners and key workers. vi Monitor Demands on Staff Demands on mental health key workers were monitored by inviting the coordinator of the work group to all meetings of the advisory group, by involving the team leader in all stages of the project, and by including staff issues in the evaluation. vii Commence Involving one Staff Member then Involve Further Staff As the project was implemented using two cycles, there was an opportunity to commence implementation with one staff member who volunteered to take a lead role in relation to approaching General Practitioners to invite them to participate in prescribing the medication Clozapine. This staff had experience in another country in working jointly with General Practitioners, and had attracted funds to support this type of work. Once Cycle 1 had commenced, the remainder of the Shared Care staff were offered the opportunity to participate in collaborative work with General Practitioners as part of Cycle 2. viii Monitor Risk Issues As the project officer was also team leader for staff in the Shared Care program, it was possible to monitor risk issues on a continuous basis, and to discuss these with staff. When necessary issues could be brought to the steering group for discussion. A number of potential clinical risk issues were identified but did not eventuate, and to this extent learning about risk issues from the project may be less than first expected. Potential risks were for marked differences to emerge in expectation between General Practitioners and mental health workers, for severe arguments about care plans leading to a need for a dispute resolution mechanism, for consumers to doctor shop to obtain extra medication, and for different opinions to emerge about the roles of each party when a client needs to be detained. In fact, none of these events occurred involving consumers in the collaborative care sample. ix Caseloads Questions arise about suitable numbers of consumers on a caseload. King, Le Bas, and Spooner (2000) reviewed relations between caseload and personal efficacy of case managers in Australian mental health services by asking 300 case managers to complete questionnaires.
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They noted that in Australia, the clinical case management role requires workers to perform a range of tasks including intake work, skill development, provide individual therapy, and participate in community development and liaison that is relevant to their consumers. This requires considerably more hands-on involvement with consumers than occurs in brokerage models where workers are involved in planning and monitoring service delivery. King et al. found that personal efficacy of case managers was related to size of caseload, with high caseloads being associated with personal distress in case managers. As caseloads increased, workers reported an inability to complete basic work including home visits when they become familiar with the consumers home environment, responding to consumers expressed needs, and becoming unable to assist consumers to access community resources. King et al identified a caseload of about 20 consumers as being associated with optimal functioning. The mental health policy implementation guide for community mental health teams published by the Department of Health in Britain (2001) recommended that full time care coordinators have a caseload of 35 consumers, dependant on complexity of consumer need. Mueser et al (1998) noted that caseloads for key workers implementing standard case management are commonly in the range 20-30. Caseloads were monitored in the ECCMH project. The topic of a suitable caseload was included in team meetings where service plans were discussed and targets were set. The Shared Care program proposed a target of 25 active clients on a caseload and 5 clients in the consultancy phase of care for a full time worker. Evaluate Change Both the EQuIP Guide (2003) and Six dimensions of quality adopted by the South Australian Hospitals Safety and Quality Council (2004) provide frameworks for conducting evaluations of health services. Webster and Raphael (2001), Moss, Saunders and Wilson (2001), and Nelson et al. (2003) have applied evaluation frameworks to functioning of community mental health services. The EQuIP framework separates measures of structure, process and outcome. Structure refers to physical and human resources. Process refers to clinical and other activities used by the service that can be evaluated by consumers. Outcome refers to results of intervention. Outcomes may be benefits experienced either by individual consumers or by groups of people. The six dimensions of quality adopted by South Australian health services are safety, effectiveness, appropriateness of care, consumer participation, access to services, and efficiency of service provision.
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Moss, Saunders and Wilson (2001) from CSIRO concluded from their review of measures to evaluate community mental health services, There is not currently available a comprehensive suite of tests that enables the accurate measurement of quality in the structure, processes and outcomes of the mental health system (page 28). Input Measures A traditional approach for assessing quality is to measure aspects of input by clinicians. Pennebaker, Vogels, Browton & Anderson (2000) examined qualities of mental health staff that are valued by consumers, and found that valued qualities were: acceptance/listening, trust, informed decisions, staff competence, protection of rights, respect, autonomy, and safety/privacy. Druss, Rosenbeck and Stolar (1999) found that some consumers linked quantity of service to consumer satisfaction, with higher satisfaction being related to fewer inpatient admissions and to higher community contacts. Compliance with Standards One approach in quality assurance is to assess level of compliance with agreed standards of practice. Weir and Penrose-Wall (1999) addressed the question of whether General Practitioners might use the National Mental Health Standards as a benchmark to assess quality of integrated care, but concluded that the National Standards are too general and not sufficiently relevant to issues that are dealt with by General Practitioners. The Mental Health Council of Australia (2000) considered the use of a TRAMHS (Tools for reviewing Australian mental health services) instrument for evaluating services, and concluded that the instrument is far too in-depth. Gournay (1996, 1997) has also written about difficulties of establishing written standards for community mental health. The ECCMH project did not identify established standards that appeared suitable for evaluating the collaborative care project. Measures of Clinical Symptoms Penrose-Wall (1998) reported that General Practitioners seek clear physical measures for symptoms or signs of illnesses to be used in individual cases to obtain feedback about how treatment is progressing, equivalent to cholesterol levels for heart disease or blood pressure for hypertension. General Practitioners view treatment of mental illness as being complex partly because there is no established simple measure of clinical outcome that can be used with individual consumers.
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A range of questionnaires are available that focus on self reports of symptoms of mental illness, as reviewed by Andrews, Peters and Teesson (1994) and Steedman, Yellowlees, Mellsop, Clarke and Drake (1997). The Commonwealth Government has recently required mandatory collection of certain questionnaire measures as part of a NOCC (National outcomes and casemix collection) process. The mandatory measures are HoNOS, Life skills profile LSP-16, and Kessler K10. When the ECCMH project commenced, NOCC was not in routine use in the Noarlunga Mental Health Division. As staff become more skilled in the use of NOCC scales there will be an opportunity to evaluate clinical outcomes using these scales. Clinical Indicator Measures Some approaches aim to measure quality of care by focusing on responsiveness of the service system, rather than on self-reports of clinical symptoms. Measures of responsiveness proposed by Stokes (2002), Maas and Foti (2000), and Weir and Penrose-Wall (1999) include: access to services, access to information, acceptability of services to consumers, staff attitudes, support for carers, reduction of relapse, and perceived appropriateness of referrals by General Practitioners. No benchmark data using indicators of positive responsiveness were found by the ECCMH project. Sentinel Adverse Events A common approach to measure quality is to focus on sentinel adverse events that are to be minimized or prevented. Adverse events listed in the Clinical Indicator User Manual for community mental health published by the Australian Council on Healthcare Standards (2003) include adverse reactions to a medication, unplanned readmission to a hospital, and mortality. Key Performance Measures Moss, Saunders and Wilson (2001) noted the need to conduct cost-effectiveness studies of different models for providing mental health services based on performance measures about the use of resources. Simmonds, Coid, Joseph, Marriott and Tyrer (2001) reviewed international literature that evaluated community mental health services to identify measurable key performance indicators. They analysed in depth 65 studies using randomized trials. Simmonds et al focused on overall cost of care, measures of mortality, and length of hospitalizations, finding positive outcomes from case management. Quality Control Methods in Community Mental Health Community mental health services are provided by multi-disciplinary teams so no one professional discipline is in a position to state overall best practice. Additionally, many consumers present with a range of difficulties or have complex needs whose management is not easily summarized using a formula that is endorsed as best practice. Instead, there is considerable reliance on the judgment of skilled clinicians who identify factors that impinge on the current mental health of an individual consumer.
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Quality assurance for clinical practice in community mental health services has been monitored using five mechanisms (National standards for mental health services, 1996): Providing an holistic assessment using a standard format that can be forwarded to other service providers Providing intervention by a multi-disciplinary treating team Providing periodic multi-disciplinary clinical reviews for individual cases that include opinions of professionals who are not directly involved in the treatment of the individual Seeking advice from recognized experts on topics where clinicians experience difficulty Involving both consumer and carer representatives in monitoring and planning service delivery
One task for the ECCMH project was to find ways of making available to General Practitioners those quality assurance methods that are used in community mental health. The shared care and consultancy phases of care were offered to enable general practitioners to participate in the quality systems that are used in community mental health services. Dissemination of Information The project is required to disseminate information about the project. Dissemination will occur through a combination of: Visiting neighbouring services to explain the collaborative care system Providing copies of the project report, and making available electronic copies Providing a brochure summarizing outcomes Submitting reports to peer reviewed professional journals Visiting other mental health sites in Adelaide and providing reports as invited Giving presentations to mental health conferences
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COLLABORATIVE CARE IN MENTAL HEALTH IN NOARLUNGA PROJECT FRAMEWORK

This section describes the ECCMH project using the headings outlined in the funding agreement. Staffing The project was implemented by a project officer who was employed 0.5fte over a period of two years. The role of the project officer was to plan, implement and evaluate changes in the community mental health system, rather than to be a specialist clinician who provided clinical support to General Practitioners. The project aimed to involve all community clinicians in the Shared Care program in working in new ways. The project was strongly supported by a liaison officer employed by the Southern Division of General Practice. The liaison officer communicated with General Practitioners in the region. Governance The project was over-seen by an advisory committee that met on a monthly basis in the evenings. The Advisory Committee comprised representatives from key stakeholder groups who were: Nominee of the Directors of Mental Health Divisions of NHS and FMC (Clinical Director of MHS of NHS) Nominee of the Southern Division of General Practice (Liaison Officer) One consumer representative nominated by Noarlunga Consumer Advisory Group One carer representative Two practicing General Practitioners nominated by the Southern Division Quality Manager of NHS Team Leader of CCT team Aboriginal Mental health worker from NHS Project Officer in attendance
Some changes in the Advisory Group occurred as the project progressed. The project officer who was first appointed resigned, and was replaced by the team leader who operated 0.5fte as team leader and 0.5fte as project officer. After the change in project officer, a senior staff represented the CCT team leader from the Shared Care program. The Noarlunga community mental health service system was reorganized during the project, and responsibility for the Shared Care program was transferred to a different team leader. Following this change the new team leader attended meetings of the advisory committee. There was regular attendance at meetings by most nominees, with especially strong attendance from representatives of SDGP, General Practitioners, and consumers and carers.
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The project reported on a regular basis to the Clinical Forum of the Division of Mental Health. Noarlunga Health Services employed three Aboriginal mental health workers during the time of the ECCMH project. Each person was invited to attend the evening meetings. Each Aboriginal mental health worker declined to attend meetings after listening to briefings, and instead raised different priority topics for the Mental Health Division to address. Aboriginal mental health workers noted that the ECCMH project focused on linking consumers to General Practitioners for ongoing care. They expressed a view that many Aboriginal consumers seek assistance at times of crisis through the emergency system and were often reluctant to form an ongoing relationship with a general practitioner. Aboriginal mental health workers were informed that the project included a proportion of Aboriginal consumers that was consistent with the proportion of Aboriginal people in the local community. Aboriginal mental health workers offered to provide information and advice to the project officer on request. Role of the Advisory Group The Advisory Group or steering committee played a very significant role in the project. All significant topics were raised with the Advisory group for comment. On many occasions the Advisory group participated as a focus group that addressed particularly complex topics, and the Advisory group spent entire meetings filling this role. All plans for implementing collaborative care were supported by the Advisory group before being implemented. The Advisory group received feedback on all initiatives that were implemented. Members of the Advisory Group were aware that they represented stakeholder groups and they were in a position to discuss topics with the groups they represented if required. Members at times did take matters to their stakeholder groups for additional comment. Some funds were available to support participation of stakeholder focus groups to address especially complex topics. The Advisory Group prepared questionnaires that were used to evaluate the project to ensure that issues important to stakeholders were included in the evaluation. Financial reports were provided to the Advisory Group on a regular basis and when requested. Terms of Reference Terms of Reference for the project included purpose, goals, objectives and indicators. Schedule 1 of the Funding Agreement for the project states as the purpose of the project, To define the critical success factors for the development and maintenance of quality management in shared care partnerships between Mental Health Services MHS and General Practitioners. This was to be achieved by asking the project to Design and evaluate systems and procedures that can be used to extend this integrated quality approach to shared care partnerships between MHS and other government and non-government agencies.
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Target Groups Target groups for the project were: Consumers and prospective consumers of the Noarlunga Community Care Team NCCT who have a general practitioner involved in their physical and/or psychiatric care. General Practitioners working in the Outer Southern metropolitan area of Adelaide, as defined by the Southern Division of General Practice; and who are involved in the physical and/or psychiatric care of consumers or prospective consumers of the NCCT. Government and non-government health and/or welfare agencies providing services to consumers of the NCCT.
Objectives Four goals were established for the project: Design a sustainable partnership approach that improves integration of services Implement the partnership approach in a manner that improves communication between stakeholders Evaluate the new system of shared care Extend the shared care partnership to other agencies
Indicators The Funding Agreement outlines a number of indicators. Addressing needs of Aboriginal consumers Sustaining progress by using the Medical Benefits Scheme Enhanced Primary Care items to provide a financial incentive for General Practitioners to continue to participate in the shared care partnership. Incorporating systems and processes into service delivery guidelines for Noarlunga MHS Develop a joint Shared Care agreement between Mental Health services and the Southern Division of General Practice
Outcomes The Funding Agreement identified as expected outcomes of the project: A quality system of shared care that is effective, consumer focused, meets consumer and practitioners definitions of quality, is sustainable, and can be generalized across mental health services. Documentation of the system (eg care plans, workbooks, audit tools) Dissemination of the project using systems such as peer reviews and web sites so as to facilitate adoption of the system elsewhere.
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Evaluation Strategy The funding submission proposed an evaluation strategy that involved CSIRO as an external evaluator. Contact was made with CSIRO during the early period of the project. It then became apparent that the funding submission was based on a view that a change in service delivery had already occurred and was awaiting evaluation. In fact the advisory group identified considerably more development of the model of service delivery as being required before evaluation commenced. The involvement of CSIRO ceased at this time. The funding submission proposed that a research steering committee be established consisting of stakeholders to oversee the evaluation. The ECCMH advisory group filled this role. The participatory action research paradigm involved cycles where ideas were clarified, implemented, monitored and evaluated, leading to revisions of the model for providing services. While the PARP model includes a component of evaluation, the PARP model is viewed in this project as being primarily part of the framework for developing concepts. Planning for evaluation in the ECCMH project was completed before the document Six dimensions of quality became available to the project team. The evaluation strategy used in the ECCMH project focused on two types of quantitative feedback involving: Satisfaction of stakeholders on identified partnership processes using questionnaires that were developed by the ECCMH advisory group to address topics identified as being critical to the success of the partnership Measures to assess performance on topics arising from the model Six dimensions of quality including equity of access, appropriateness of care, consumer participation, effectiveness, efficiency of service, and safety
All of the measures above can be used at an organisational level as part of an ongoing quality assurance process. Evaluation focused on a sample of 60 consumers that comprised half of the consumers in the Shared Care program. The evaluation strategy was planned by the advisory group and was implemented by an independent evaluator and the project officer. Changes to Goals The project team did not propose any changes to the goals and objectives expressed in the funding agreement.
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Timetable The timetable of events in the project can be summarized as occurring in eight periods: The project commenced and set up in April 2002 Establish the project advisory group and employ a project officer (2 months) Cycle 1 comprised planning and implementation of partnership agreements for consumers receiving Clozapine medication that is prescribed by the General Practitioners (7 months commencing May 2002) Cycle 2 involved planning for a partnership for a second group of consumers with chronic illness and disability, producing a new model of collaborative care based on four phases of care (8 months commencing November 2002) Implementation of the new model of collaborative care for consumers with chronic mental illness for Cycle 2 (12 months commencing July 2003) Project work was suspended in March 2004 while a reorganization of the community mental health teams occurred Evaluation of the new model of care based on a sample of consumers (3 months commencing October 2004) Final writing up of the project (4 months)
A further disruption to the project occurred when a hostel for people with mental illness in Adelaide city closed and a number of people were accommodated in the Noarlunga area and were referred to the Shared Care program. This increase in demand for clinical time drew attention away from the ECCMH project for a period, and raised needs of consumers who lived in supported accommodation. Overall Cost of Project The ECCMH project operated within the budget provided. The Southern Division of General Practice assisted the project significantly by making available time from their Liaison Officer. Noarlunga Health Services also contributed in a variety of ways including making available time of all of the staff who attended evening meetings of the advisory committee, provision of goods and services including administration support, a room and desk, computer facilities, photocopying and so on.
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IMPLEMENTATION OF PROJECT
This section describes the detailed steps required to plan a new system of care. Cycle 1- Clozapine Planning a System of Collaborative Care In the case management system of care, MHS staff and General Practitioners worked successively or one after the other so that at any point in time one or other party is responsible for care. The new form of collaborative care is distinctive as both the General Practitioners and MHS staff work concurrently or simultaneously with the consumer in phases of joint care. A simultaneous approach to care is viable if there are reasonably clear responsibilities for each partner. When the ECCMH project commenced, a new system of collaborative care involving General Practitioners and mental health staff working simultaneously with consumers was being introduced in Adaire Clinic for consumers who received Clozapine medication. The new system of collaborative care involved a number of features that appeared likely to inform the larger project. Features of the Clozapine partnership that appeared relevant for the larger project are summarized below. Good Clinical Practices for Cycle 1 Established clinical practice when prescribing Clozapine in a shared care partnership is recorded in a manual provided by the pharmaceutical supplier Novartis called, Clozaril shared-care program protocol (Novartis, 2003). The mental health clinic assesses the suitability of Clozapine for an individual consumer, discusses the option of taking Clozapine with the consumer, and with the informed consent of the consumer commences Clozapine medication. The clinic provides total care while Clozapine medication is being introduced and stabilized. The clinic assess when the consumer is ready for a shared care arrangement. The shared-care arrangement is summarized in terms of the following clinical practices. The general practitioner performs the following: General practitioner makes monthly appointments with the consumer, checking compliance and side effects including general health measures of blood pressure, monitors mouth and throat, temperature, heart sounds and pulse rate. General practitioner organizes for consumers scheduled blood tests to be conducted by a pathology service within two days of the appointment, with the General practitioner receiving results.
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General practitioner assesses mental state and white cell and neutrophil count. If satisfied with white cell and neutrophil counts, General practitioner writes a repeat prescription with the same dose and frequency as determined by the clinic psychiatrist. General practitioner notifies the clinic Clozapine Coordinator if concerned. General practitioner notifies Clozapine Coordinator if consumer does not attend.
The consumer does the following: Consumer attends General Practitioner appointments Consumer takes prescription to pharmacist for Clozapine to be dispensed.
Pharmacy does the following: Pharmacy sends copies of the Clozapine dispensed to the Clozapine Coordinator.
Mental health services do the following: Provides a nurse with the role of Clozapine Coordinator who coordinates with general practitioners, functions as key worker, and enters information on the Clozapine monitoring system Provides a psychiatrist who reviews clients at 6 monthly intervals or as requested by the General practitioner
Selection of Consumers Consumers who received Clozapine medication were selected as being suitable for a shared care arrangement where the General practitioner took over prescribing if the following inclusion criteria were met: The consumer could nominate a General practitioner to be the treating doctor The consumers mental state was stable The dose of medication was stable
Selection of General Practitioners General Practitioners were invited to participate in the shared care project on the basis of being nominated by a selected consumer as being the consumers usual general practitioner. Treating Team Initial decisions about a treatment program for a consumer who commences Clozapine are made by the treating team involving the treating clinic doctor, consumer, key worker, and carers where relevant.
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Once a shared care partnership has commenced, the general practitioner participates in making decisions about the treatment via the joint community care plan. Informed Consent Use of Clozapine medication has inherent risks of certain physical side effects. Consumers are fully informed about the expected benefits and risks of using Clozapine medication and give written consent to participate in the Clozapine program. Confidentiality Clinical information is shared within the treating team as guided by a confidentiality agreement that is consistent with privacy principles outlined in a pamphlet given to all consumers Privacy and your personal information (Department of Human Services, 2003). Professional Training The Southern Division of General Practice operated a Mental Health Joint Training Working Party that addressed issues of continuing professional education for General Practitioners on mental health topics. This working party offered to assist the ECCMH project both to identify topics where training was required and to organize this training. Training about Clozapine was provided for General Practitioners who expressed an interest in prescribing Clozapine by a team comprising the Clozapine Coordinator, Clinical Director and consultant psychiatrist. Further training for General Practitioners was provided in a group session that covered the topics of schizophrenia, Clozapine medication, and how the community mental health service operates. The Clozapine Coordinator trained other clinic staff in practices around use of Clozapine. Backup for General Practitioner The Clozapine Coordinator assists General Practitioners to become registered as a Clozapine prescriber. Where a General Practitioner agrees to prescribe Clozapine, this General Practitioner was asked to nominate a second General Practitioner to provide backup during times of absence such as annual leave. Consumer Education Consumers were informed about the proposed new model where care is shared with their General practitioner. Consumers were informed by their key worker and were also invited to group sessions along with their carers. The group sessions also served as a focus group as feedback from consumers and their carers was passed on to the project team.
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Ongoing Access from Specialist Service The mental health service provided a structured back up system for General Practitioner and was available to the General Practitioner if consumers become unstable while on the medication, by providing a clear pathway for General Practitioner to access follow-up support. Indicators to be Monitored for Quality Assurance The pharmaceutical manual outlines physical indicators of good health that are monitored monthly by the general practitioner when a repeat of a Clozapine prescription is issued. Data about the physical indicator are entered by the Clozapine Coordinator onto a computerised CPMS monitoring system that is provided by the pharmaceutical company. The CPMS manual recommends monitoring of further physical symptoms that is carried out periodically on a 6 monthly basis by the clinic consultant psychiatrist. Role of Pharmacists Only pharmacists who are registered with the CPMS system can dispense Clozapine medication. One pharmacy was selected in the initial period to dispense Clozapine. Close communication is required between stakeholders, who are the mental health service, General Practitioner, blood testing agency, pharmacist, consumer and carer. This communication is set up by the clinic Clozapine Coordinator. Transfer of Prescribing The clinical process for transfer of prescribing for a consumer who receives Clozapine involves the clinic consultant psychiatrist and Clozapine Coordinator discussing the proposed transfer with both the consumer and the general practitioner who is nominated by the consumer as the usual treating general practitioner. The nominated General Practitioner then receives training as described above. Joint Care Plan The multi-disciplinary community care plan included in the EPC kit was identified as providing the most suitable basis for clinical communication between the mental health service, consumer and General Practitioner. Education for preparing joint care plans Education about preparing joint care plans was provided for key workers based on the protocol given in Appendix 4.
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Reimbursement The General Practitioner claims remuneration for participating in preparing the care plan using an EPC item 720. The General Practitioner claims for an extended appointment time using one of the Medicare EPC items as outlined in Appendix 7. A review of the care plan can be conducted each three months using EPC item 724. Implementation of Cycle 1 The plans above were all implemented. Selection of Consumers When the shared care in Clozapine project commenced, 27 consumers of Adaire were prescribed Clozapine. Of these 22 had a nominated General Practitioner. In May 2002 four consumers were nominated for shared care with a General Practitioner. Some of these consumers had difficulty attending Adaire Clinic because the consumer was working or attending university, but could see their General Practitioner. During the course of the ECCMH project a further five consumers on Clozapine were nominated for shared care and were included in the sample. Education for General Practitioners A training session was provided in November 2002 for General Practitioners who were asked to participate in prescribing Clozapine to learn about schizophrenia, about the Clozapine protocol and the shared care approach. All invited General Practitioners attended the educational session. General Practitioners were assisted to register with CPMS as being a Clozapine prescriber. All General Practitioners organized alternative arrangements for prescribing to cover a possibility of non-availability for any reason. Reimbursement All consumers were bulk billed as General Practitioners received extra funding for Clozapine prescriptions using EPC items. Education for Consumers and Carers Education about the shared care program involving Clozapine was provided to consumers both by their key worker and in a five group sessions where carers were also invited. Topics covered were: schizophrenia, early warning signs, self care, medication, diet and exercise, shared care in liaison with General Practitioners, joint care plans, and protocols on receiving Clozapine. Ongoing education sessions were provided every four months.
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Support from Adaire Clinic The Clozapine Coordinator provided initial training to General Practitioner reception staff about the Clozapine protocol and on the importance of consumers attending for appointments. The Clozapine Coordinator arranged the first appointment with the General Practitioner and attended that appointment to provide a smooth handover. Evaluation of Cycle 1 Feedback sheets were provided during group sessions with consumers and carers. Concerns raised by consumers and carers that were reported during the consumer and carer sessions are noted in Table 2 together with answers given.
Table 2. Expressed concerns of consumers
Expressed Concerns
Stress of changing over to General Practitioner Long wait in waiting room What about if away on holiday? Where will I get blood tests done? Are General Practitioners properly informed? How do I access Adaire if I need to? Will General Practitioners pick up early warning signs? Do I have to move? How can I look after myself?
Solution
Change will occur gradually at a time that suits the consumer Ask for first appointment after lunch Arrangements can be made via Adaire clinic Any pathology service can take blood for tests. General Practitioners have attended training, and are supported by Adaire Clinic. Contact your previous key worker or ACIS. Early warning signs are recorded on the care plan and General Practitioners are trained to notice these. The change is not compulsory. There are benefits to seeing your General Practitioner. You can attend ongoing support groups.
General Practitioner Concerns Concerns raised by General Practitioners were addressed during the education and feedback session. One concern involved questions about the capacity of consumers to give informed consent to treatment. Refinements from Cycle 1 Adjustments were made to the care plan following experience in Cycle 1. A section was added to allow recording of early warning signs of relapse. The name of the plan was changed to Joint Care Plan.
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A copy of the revised form is given in Appendix 3. Cycle 2 Consumers With Chronic Illness Planning for Cycle 2 Experience from the first cycle involving consumers who received Clozapine assisted the ECCMH advisory committee to plan for key issues that needed to be resolved for a partnership involving the second group of consumers with chronic illness. Decisions made by the advisory group on each of the key issues identified in the first cycle are given below. Selection of Consumers It was agreed to invite 60 consumers to participate both in a new model of collaborative care and in the formal evaluation. Initial inclusion criteria were that the consumer: Could nominate a treating General Practitioner Mental state had been reasonably stable for a period of some months Medication prescription was stable and could be continued by a General Practitioner The consumer may have physical health issues that were already being treated by their General Practitioner
Further inclusion criteria were set so that the project would address a number of perceived barriers when transferring care to the consumers General Practitioner. Perceived barriers to discharge were: Consumer received Clozapine medication that requires very close monitoring Consumer was on a Community Treatment Order CTO or an administration order Consumer received disability support from a non-government agency for mental health reasons, requiring coordination Consumer was reluctant to be transferred or was dependent on mental health services
Consumers were nominated by their key workers to include individuals with all of the characteristics above. Note that all inclusion criteria refer to characteristics of consumers, not to characteristics of General Practitioners.
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Exclusion Criteria Some consumers with very complex needs were not included in the sample. Consumers were excluded from the project if they were very itinerant, expressed strong resistance to having a General Practitioner, or if their mental health was very unstable. Key Partners The Advisory Committee identified the following as key stakeholders for the second cycle of the project: community mental health services, practicing General Practitioners, Southern Division of General Practice, consumer representatives, carer representatives, and those non-government agencies that provided disability support to consumers. All but the last group was represented on the Advisory Group. Mental Health Service Providers In the Clozapine project, support for participating General Practitioners was provided through one designated nurse, the Clozapine Coordinator. In cycle 2 it was decided to encourage all community mental health staff who had a role of key worker to liaise with General Practitioner for the consumers they knew well. Key worker staff in the Shared Care program included a clinical nurse, registered mental health nurse, social worker, enrolled nurse, and paramedical aide. An experienced registrar supported the Shared Care program. There was some change in personnel during the course of the project. New Model of Collaborative Care Based on Phases of Care One aim of the ECCMH project was for the mental health service to adjust its responses to consumers according to the stage of recovery the consumer was in, so as to provide greater continuity of care for consumers as they were transferred to the care of their General Practitioner. The current system was based on two phases of care, as care was coordinated either by the mental health key worker or by the General Practitioner, and the consumer was either registered with the mental health service or discharged. The Clozapine model introduced a third phase of care called shared care as both the mental health service and General Practitioner had defined simultaneous responsibilities that are stated in the care plan. It was decided to add a fourth phase of care for consumers who have a chronic mental illness as many consumers progress to the point where there is no longer an active role for the mental health service as routine care is provided entirely by the General Practitioner. The fourth phase of care is called consultancy.
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Participation by General Practitioners General Practitioners were selected for the collaborative care project on the basis of being nominated as the treating General Practitioner by consumers who were selected. All nominated General Practitioners were informed in writing about the collaborative care project and were invited to participate for a nominated consumer. A copy of the model with phases of care was forwarded to the General Practitioner stating the phase of care the nominated consumer was assessed as being in. Treating Team A new form of treating team for shared care consumers was recognised where the General Practitioner became a member of the team along with the key worker and clinic doctor. The level of involvement of the General Practitioner varies according to the phase of care as defined in Table 1. Contact with General Practitioner It was proposed that key workers contact the nominated General Practitioner when the consumer is first referred to commence the communication process. Informed Consent It was agreed to view all consumers in shared care and consultancy arrangements as being able to make their own decisions and to give or withhold consent to proposed treatments after receiving information from their treating team. This principle applied to consumers who had previously been on a community treatment order, to consumers currently on a community treatment order when issues of physical health required a decision, and to consumers on an administration order. Confidentiality Principles New confidentiality arrangements were made for consumers in shared care arrangements so that clinical information could be exchanged within the treating team to enable appropriate care plans to be developed. The DHS Code of Fair Information Practice that was being introduced at the time informed the new confidentiality arrangements. Consumers gave verbal consent to follow the new confidentiality principles. Communication Instrument Prior to the ECCMH project, communication with General Practitioners had occurred primarily through phone calls and letters from the clinic to the general practitioner.
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The project team recommended the EPC multi-disciplinary community Care Plan also called the joint care plan as the primary instrument for clinical communication between the General Practitioner and mental health clinicians. The joint care plan format provides basic information about relevant history, diagnosis, current medications, and health providers who are involved with the consumer. The joint care plan contains a table where participants identify problems, goals, management steps, and the person responsible for implementing steps. Information was added to cover early warning signs of relapse. A copy of the joint care plan format is provided in Appendix 3. There is provision for consumers to sign their joint care plan. A protocol was prepared to assist key workers to negotiate a meeting with the General Practitioner when a joint care plan is completed. This protocol was prepared in a joint meeting of staff and two visiting General Practitioners. The protocol is provided in Appendix 4. Clinical Monitoring When Cycle 2 was planned, no particular physical clinical indicator had been identified as requiring monitoring for all consumers in the sample, equivalent to cholesterol that is monitored for people with heart disease. All consumers were encouraged to use a self-management approach for their illness based on recognition of their early warning signs EWS of a potential relapse. The joint care plan was adapted so that early warning signs could be recorded in the individuals joint care plan, and the general practitioner was encouraged to monitor these early warning signs. Developments in this area are discussed below. Reimbursement for General Practitioner Reimbursement for the General Practitioner to complete a multi-disciplinary care plan is provided through EPC Item 720, and is available if the consumer and two other professionals from different disciplines are involved in addition to the General Practitioner. The mental health service undertook to provide input from two other professionals who commonly would be the key worker and clinic doctor. Educational Sessions All General Practitioners who were nominated by consumers in the sample were invited to two joint education sessions on topics that were identified by the SDGP joint working party. Educational sessions were planned in a manner that earned CME points for participating General Practitioners.
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Educational sessions covered: Presentation by a clinic doctor about mental illness and medications (schizophrenia and bipolar disorder) Information about how General Practitioners can use community mental health services, by the team leader Multi-disciplinary case discussion leading to preparation of a joint care plan, chaired by a General Practitioner Use of EPC items
Clinical Quality Assurance In the Clozapine model, quality of service provision is monitored primarily using blood tests that are monitored regularly, with results being recorded on CPMS. Other physical tests are conducted about 6 monthly. There is no equivalent physical test of illness for the mental illnesses of psychosis and mood disorders. One method of quality control used in community mental health services is the multi-disciplinary clinical review that reviews consumer management plans. There are practical difficulties in inviting General Practitioners to attend existing clinical review meetings. The advisory committee considered that a multidisciplinary joint care plan meeting that included the consumer and General Practitioner was a reasonable approximation to the method of quality control used in community mental health services. The advisory committee supported use of a Joint Care Plan for quality assurance. Another method of quality monitoring that is being introduced in community mental health emerges from the approach of self-management of a chronic disease, where consumers are taught to identify early warning signs of a possible relapse and to take appropriate action when these warning signs are detected. The care plan format was adjusted to include early warning signs so that all parties were aware of this information. Recording of early warning signs in care plans can be used as a measure of quality of care in promoting consumer independence. Structure of General Practitioner Visits Unlike the case with Clozapine medication, no general principle was identified to recommend a frequency for consumers to visit their General Practitioner. Some medications such as depot medications require attendance at a certain frequency. Frequency of appointments was a topic to be addressed on an individual basis in care plans. Access Pathways The new model of collaborative care provided a means for General Practitioners to access mental health staff for consumers in all phases of care. However this access was time-limited.
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Planning sessions found that key workers were confident about being approached while they were working actively with a consumer during the first three phases of care. Key worker confidence about being approached by a General Practitioner remained high for a period of about six months following transfer of care to the General Practitioner in the consultancy phase. After a period of about six months, key workers doubted that old assessments would still be relevant, and preferred that contacts from General Practitioners for consumers who had moved into General Practitioner care be directed to another part of the community mental health service. Non-medical Liaison A Discussion Paper was circulated within the mental health division about how best to provide an ongoing consultancy service for General Practitioners by nonmedical mental health workers especially for consumers who had been discharged to the care of General Practitioner some years earlier. Change Management When Cycle 2 commenced general criteria for consumers to enter each phase of care were available as given in Table 1. There were no precise operational definitions that are equivalent to a blueprint for action. Some staff expressed concern that they were being asked to commence the project on the basis of limited definitions. Staff were encouraged to think about their task as being equivalent to the task of travellers who are asked to explore an area that has not yet been mapped and where there are known hazards. The essential techniques to conduct this type of exploration safely is for a group with a variety of skills to work together, for the group to move slowly and carefully, for the group to communicate frequently about both concerns and prospects, for the group to exchange information and to express trust in one another, for the group to have the confidence to make immediate decisions themselves, and for the group to maintain contact with a support system. Observations by a safe group of travellers enable a better map to be prepared and to be passed on to future travellers. Implementation of Cycle 2 When the collaborative care system commenced formally in July 2003, the Shared Care program had 123 registered consumers. A sample of 60 consumers who met inclusion criteria were invited by their key workers to participate in the new form of collaborative care that involved a higher degree of coordination with their general practitioner than had previously occurred. The main change for consumers was that the new model of collaborative care provides four phases of care in place of the previous two phases of care.
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Participation by Consumers Of the 60 invited consumers, 55 accepted the invitation and 5 declined, giving an acceptance rate of 92%. Five further invitations were issued to maintain a sample of 60 consumers. Characteristics of the final sample are given in Table 3. Operational Definitions The following definitions were used when gathering data for Table 3. Age, length of episode, and diagnoses are those at the commencement of Cycle 2 in July 2003. Items under Barrier to discharge are counted if the item occurred either during the 12 months of the study period from July 2003 until June 2004, or in the year prior to the study (from July 2002). NOCC scores that were available in December 2004 were used. There were 27 Honos scores and 23 LSP scores.
Participation by General Practitioners General Practitioners were selected in cycle 2 on the basis of being nominated by selected consumers as being their treating General Practitioner. A letter was sent to nominated General Practitioner in November 2003 inviting participation in the project for a nominated consumer, together with a one page information sheet that included the model based on phases of care, a statement about the confidentiality principle, and about philosophy of care. This process resulted in 34 General Practitioners and one private psychiatrist being nominated to participate in the project. Of these, 1 General Practitioner cared for 5 consumers, 4 General Practitioners for 4 consumers, 3 General Practitioners for 3 consumers, 3 General Practitioners for 2 consumers, and 24 doctors for one consumer. Some changes occurred in treating General Practitioners during the year of follow-up. At the time of the follow-up all consumers still had a nominated treating general practitioner. Training for General Practitioners Two training sessions were provided for General Practitioners in October/November 2003, covering topics of schizophrenia and bipolar disorder. Fourteen General Practitioners attended from twelve practices, together with two staff of MHS in addition to the presenter.
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Table 3. Description of Sample
CHARACTERISTIC
Gender
DATA 30 30 41.7 years 21-75 years 56 3 1 5.4 years 0.5 to 18 years 35 9 8 4 2 2 12 8 6 27 7 Mean 11.9, range 1 24 Mean 13.4, range 1 36

Age
Male Female Mean Range European Aboriginal Asian Mean Range Schizophrenia Schizo-affective disorder Bipolar disorder Dependent personality Delusional disorder Depression Clozaril medication CTO Administration Order Disability support service Dependence HoNOS LSP
Race
Length of Episode
Primary Diagnoses
Barrier to discharge
Mean NOCC scores and range
Participation by Key Workers During the time of the ECCMH project, the Shared Care program was staffed by the equivalent of 4 fte positions that were occupied by six workers who held positions of clinical mental health nurse, social worker, mental health nurses, enrolled nurse, and paramedical aide. A consultant psychiatrist and a registrar supported key workers. Education for Key Workers Education was provided for key workers in the Shared Care program. One method of education that proved to be very effective was to invite General Practitioners who were participating in the shared care project to attend a meeting of staff so that people could meet personally and discuss issues around the shared care partnerships. These educational meetings were funded by the ECCMH project.
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Education was provided for key workers covering the topics of: joint care plan with General Practitioners, EPC items, and how to make appointments with General Practitioners to complete a care plan. A copy of a completed example care plan was provided. Information to Consumers and Carers All consumers were provided with information via their key workers about the new collaborative care system. In addition the project officer addressed a meeting where all consumers and their carers were invited. Feedback was received at this meeting. Phase of Care Key workers were asked to identify the phase of care the consumer was in, both at the commencement of the project and at the end of the project. No formal tests of reliability of assigning phases were conducted, as this appeared inappropriate when no operational definitions were available. Key workers who had been employed at the commencement of the project were able to nominate a phase of care for every consumer. These key workers also contributed to discussion about how to improve operational definitions of criteria for referring consumers into each phase of care. On the other hand, key workers who had joined the Shared Care program after the ECCMH project commenced had difficulty in nominating phases of care for consumers on their caseload. Refinements from Cycle 2 As part of the participatory action research process, mental health key workers who had participated in the project from the commencement in July 2003 commented about the following topics at the end of Cycle 2: Staff training material Refinements to definitions Attitudes required in each phase of care Process issues for improvement
Points raised are summarised below.
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i Staff training material Based on experience from Cycle 2, improved staff training materials have been provided for the following topics: Care Plans, as shown in Appendix 5 EPC items, as shown in Appendix 7.
It is acknowledged that there is a need for ongoing staff training on a number of topics including self management, recovery, carer issues, risk attitudes, expectations of case management, use of EPC items, liaising with General Practitioners, and liaising with carers. RECOMMENDATION 3: That ongoing staff training be provided to cover skills required of mental health workers who participate in collaborative care with General Practitioners. ii - Refinements to definitions By 2004 staff of the Shared Care program had produced a new draft service plan to further clarify the role of the program. The Shared Care program is for consumers who require longer term care that will be provided in partnership with other services including a general practitioner, disability support services and other agencies. Shared Care accepts referrals from other community mental health services who have provided therapeutic interventions and linked consumers to relevant community services. The Shared Care program consolidates interventions that have been commenced by the referring service and accepted by the consumer, by providing these interventions at a less intense level. Consumers are assessed as requiring a combination of ongoing rehabilitation, relapse prevention and some acute work and crisis management support. On referral consumers have a stable mental state and are not in an acute stage of illness or in crisis. Consumers are expected to move through phases of care that are associated with reducing involvement by mental health staff to prepare the consumer gradually for discharge from the service. The role of carers in supporting consumers is facilitated. In this context, more operational definitions of each phase of care were introduced based on the following proposed indicators that clients were suited to each phase of care: that a consumer is ready for each phase of intervention roles of each professional.
Specialist Care The specialist care phase of the Shared Care program is for consumers who have already received specialist input from a community mental health team, and who are assessed as requiring several months of continuing multi-disciplinary input from a clinic doctor and key worker to maintain progress.
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The consumer has some of the following features: Has experienced severe symptoms of illness in the last three months. Medication is still being monitored and may be adjusted by a treating doctor in the mental health service Consumer is receiving ongoing education on self management of the illness Consumer is receiving ongoing assistance to manage lifestyle issues or environmental problems that have precipitated episodes of illness Consumer refuses to see a General Practitioner Consumer is disorganised and is unlikely to attend appointments without reminders Consumer is predicted to relapse within 6 months if not seen regularly by the clinic
Shared Care A consumer is referred to the shared care phase if there is a clear contributing role for both a key worker and General Practitioner, with the clinic having a role of consultancy to other professionals. Consumers have many of the following characteristics: Consumers mental state and life situation have been stable for three months Consumer understands and accepts diagnosis and recommended treatment Medication has been stabilised and can be prescribed by a General Practitioner Consumer is able to keep appointments Consumer will contact the general practitioner if early warning signs occur Consumer may have a physical illness that is being treated by a General Practitioner Consumer may be under a legal order involving treatment or finances requiring oversight by mental health services Carers are knowledgeable about the consumers condition and are supportive
Consultancy A consumer referred to the consultancy phase is able to receive services from a General Practitioner. The General Practitioner maintains a link with the clinic so as to be able to access advice on request. The consumer has some of the following characteristics: Consumer regularly sees a primary health practitioner such as a General Practitioner
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Consumers care is managed predominantly by a non-government support service Consumer has learned the skills of self management and knows to approach the clinic through an agreed channel if early warning signs occur Consumer requires access to the clinic mainly to provide precautionary support Consumer is reactive to occasional stressors and seeks assistance from mental health service Carers express high levels of emotion about the consumers future that impact on consumers mental state, in a manner that is resolved by providing a contact
General Practitioner care A consumer referred to General Practitioner care has no greater need than other people to be registered with the mental health service and can re-access mental health services by following an agreed pathway to care. The consumer has the following characteristics: Consumer regularly attends appointments and cooperates with treatment Consumer asks to be transferred to General Practitioner care Consumer has self managed for a period of six months without a need to contact the clinic
RECOMMENDATION 4: Invite staff of the Shared Care program to review operational definitions that distinguish phases of care to increase confidence in use of each phase of care. iii Attitudes towards consumers in each phase of care As consumers achieve different stages of recovery and move into different phases of care, changes are required in the supportive attitude that is displayed by their treating team. Significant changes in practice by the treating team are required as a consumer recovers and progresses through phase of care as summarised below. Specialist Care Key worker pro-actively contacts the consumer at an agreed frequency to review mental health issues. Key worker contacts the general practitioner on receiving a referral and at periodic intervals to pass on information. Shared Care Key worker initiatives contact with the consumer at agreed intervals. Key worker initiates contacts with the General Practitioner. Key worker performs activities stated in the joint care plan. Key worker reduces frequency of initiated contacts with consumer. Key worker encourages consumer to resolve own crises.
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Consultancy Key worker responds to requests from the General Practitioner who is the primary point of contact for the consumer and carer. Key worker accepts that the consumer is able to initiate contact with services as required. RECOMMENDATION 5: That the Division of Mental Health promotes attitudes towards client care that are appropriate in each phase of care. iv Transfer process To facilitate transfer from Specialist Care to Shared Care, a new formal Transfer of Care form was requested. Meadows (2002) described a transfer of care form used in the Melbourne CLIPP program that provides the following information. Current diagnosis and significant past diagnoses History of symptoms, including early warning signs, symptoms of severe illness, and ongoing symptoms History of medications and responses Steps in management plan to maintain stability Recommended frequency of visits to General Practitioner Response to non-attendance Continued involvement of mental health service
RECOMMENDATION 6: That the Division of Mental Health consider routinely providing General Practitioners with information used in the CLIPP program when transferring care to the general practitioner. v Monitoring for side effects of medication While the ECCMH project was in progress literature was being published about issues that require monitoring with consumers who take anti-psychotic medications (Citrome & Jaffe, 2003; Lebovitz, 2003; Liebzeit, Markowitz & Caley, 2001). Early antipsychotic medications were effective in reducing positive symptoms of psychosis, but produced two notable side-effects called tardive dyskinesia TD and extra-pyramidal symptoms EPS. New anti-psychotic medications were introduced that have been called second generation antipsychotics. The second generation medications are more effective in reducing negative symptoms of psychosis, and are less likely to produce the side effects of TD and EPS.
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There have been reports that people with schizophrenia had higher than expected incidence of weight gain, diabetes, and abnormal lipid profiles (Leibzeit, Markowitz, Caley, 2001; Marder et al., 2002). These diseases are all risk factors for cardiovascular heart disease, and there are reports that heart disease is the commonest cause of early death in people with schizophrenia, with people treated for schizophrenia having a mortality rate from heart disease that is two or three times higher than the general population (Lean & Pajonk, 2003). There has been debate over whether the higher incidence of metabolic disorders arises from the mental illness, from the lifestyle followed by patients, or from medications used to treat the illness (Abidi & Bhaskara, 2003). Multi-disciplinary consensus reports have been published following a Mount Sinai Conference on the Pharmacology of Schizophrenia in 2001 (Marder et al, 2002). A Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes (2003) produced an agreed statement from four associations (American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, and North American Association for the Study of Obesity, 2004). Both statements indicate there is an association between the use of second-generation anti-psychotics and the metabolic diseases of obesity, diabetes, and abnormal lipid profile. The consensus statement from the four associations recommends monitoring both at baseline and at an ongoing frequency using the measures given in Table 4. The consensus statement recommends that the treating psychiatrist refer patients with risk factors to an appropriate health care professional who has specialist knowledge about metabolic disorders. A report about an effective community based intervention to manage weight gain that was conducted in the Noarlunga clinic is provided by Rathjen (2004).
Table 4. Monitoring protocol for people receiving antipsychotic medications
MEASURE Personal / family history of obesity, diabetes, dyslipidemia, hypertension, cardiovascular disease Weight and BMI Waist circumference Blood pressure Fasting plasma glucose Fasting lipid profile
FREQUENCY Annually Monthly Annually 12 weeks, annually 12 weeks, annually 12 weeks, every 5 years
The finding that antipsychotic medications are associated with metabolic disease raises a dilemma for therapists. Existing information is that if schizophrenia is left untreated then episodes of illness become more frequent and more severe, and that recovery is more difficult and less comprehensive when treatment is recommenced following a relapse (Davis & Andriukutis, 1986). Schizophrenia is a chronic disease that requires lifelong treatment if relapses are to be avoided. The information that treatment for schizophrenia itself introduces significant risk factors raises a dilemma for therapists.
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Adibi and Bhaskarara (2003) propose that the dilemma about provision of treatment be resolved on the basis of two principles: a good relationship between the doctor and client over the long term, and the client making an informed decision about treatment during periods of wellness. RECOMMENDATION 7: That the Division of Mental Health adopt the monitoring system recommended in the Mount Sinai conference for clients who are prescribed anti-psychotic medications.
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COLLABORATIVE CARE IN MENTAL HEALTH IN NOARLUNGA EVALUATION STRATEGY

Overview of Quality Assurance Measures The ECCMH team sought feedback from all stakeholders on two main topics: Dimensions of care Partnership processes
Ethics approval was obtained to approach consumers, carers, general practitioner, and disability service agencies to obtain feedback about experience of the new form of service delivery. Dimensions of Care Dimensions of care were identified using a framework provided by the quality professional in the steering committee. Topics were: Safety of care relating to avoidance of harm to consumers arising from either actions or workers or from the environment, and minimizing risks arising from care processes. Appropriateness of care based on likelihood that interventions will produce the desired outcomes, according to available evidence. Effectiveness of care relating to the extent to which consumers actually obtain measurable benefit from care they receive. Consumer participation referring to provision of input by consumers in planning, delivery, monitoring and evaluation of service delivery. Efficiency of service provision referring to the use of resources in achieving value for money. Access to service referring to the equitable availability of services to people according to consumer need, irrespective of geography, socio-economic group, ethnicity, age or gender.
Table 5 gives an overview of the detailed measures gathered within the framework of Six Dimensions of Care. Partnership Processes Partnership process that were considered key to success of a collaborative project were identified by the steering committee, and questionnaires were developed for five stakeholder groups covering identified topics that included six process topics (communication, working together, communication instruments, confidence of practitioners, sharing of information, and payments) and two outcome measures (standards of care, and overall satisfaction). The five stakeholder groups were consumers, carers, general practitioners, non-government disability support agencies, and mental health clinicians. Revisions were made to the questionnaires based on experience in conducting interviews. Copies of revised questionnaires are given in Appendix 8. Questionnaires gathered both quantitative and qualitative information.
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Quantitative answers were rated on a six point scale to allow comparisons both between topics and across stakeholder groups. The use of a quantitative scale allowed topics that received generally satisfactory ratings to be separated from topics that received unsatisfactory ratings and that require further attention in another cycle. Ratings on the scale are labeled: NA 0 1 2 3 4 5 Not applicable Needs a lot of improvement Needs some improvement Acceptable Good reasonable service Very good service Exceptional service
Note that the scales use only positive ratings, giving measures of level of approval. Questionnaires also gathered qualitative comments to provide information about the nature of changes sought by stakeholders, and to cover additional topics that were not included in the eight critical success topics. Evaluation of partnership processes was conducted independently of the project officer and service providers. Evaluation was carried out by a mental health professional with experience in conducting evaluations, with assistance from both consumer representatives and a carer representative who received training both in objective interviewing and in use of the questionnaires. A full copy of the full report by the independent evaluator is available from the project officer.
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Table 5. Overview of quality issues and measures
ISSUE Safety - Sentinel events Appropriateness of care Indicators of positive consumer outcomes
MEASURE Suicides Medication errors Stakeholders ratings on Standards of care Stakeholder ratings on Overall satisfaction with care Progress through pathway of care
Effectiveness
HoNOS, LSP scores Focus of care Admissions to ED Admissions to psychiatric inpatient unit Use of mental health services by discharged consumers Participation by representatives in project Complaint system Percent of consumers signing care plans Record of early warning signs in care plan Participation in collaborative care arrangement Number of consumers receiving collaborative care service Proportion of consumers with a nominated general practitioner Percent of consumers in each phase of care Involvement of Aboriginal consumers Consumers with other disabilities Number of contacts made in each phase of care Reimbursement for general practitioner Satisfaction ratings from stakeholders on communication, working together, instruments of communication, confidence of practitioners, sharing information, & reimbursement Communication using preferred care plan instrument
Consumer participation
Access
Efficiency of care
Partnership processes
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Experimental Design A primary purpose of the ECCMH project was to develop a new system for working in partnership in place of a system where professionals worked in isolation from one another. Priority was given to promoting sustainable changes in service delivery. The ECCMH project sought measures that can be used as part of a repeated measures design. Measures were gathered at least once as part of the project. The project did not use experimental designs such as comparing measures between a treatment group and a control group. All consumers in the Shared Care program were introduced simultaneously to the new collaborative care approach to produce changes in the system that was generalised to all consumers and clinicians. The main difference in intervention between groups is that only individuals in the sample were invited to participate in the formal evaluation. The project did not conduct a before/after analysis as the key measures of consumer satisfaction were being developed during the course of the project and were informed by activities in the project. The measures of consumer satisfaction were not available when the new form of service delivery commenced. When opportunities were available to repeat measures, this was done. Data on Topics Evaluated Safety Safety refers to occurrence of adverse events to consumers. An analysis was made of numbers of sentinel events involving consumers in the sample, as defined by the Department of Health in a letter dated 22 November 2004 requiring mandatory notification of defined sentinel events. The sentinel events most relevant for a community mental health service are: Suicide of a consumer Medication error Incidents of self-harm and aggression are considered relevant but were not recorded in a manner that could reliably be used by the project. Suicides A review of the organisational record of sentinel events found no suicides of consumers either in the sample or in the larger population of shared care consumers during the study period from July 2003 to December 2004. Simmonds et al (2001) reviewed literature on deaths by suicide of consumers in community mental health teams and reported a death rate of between 1.7% and 3.8%.
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Medication Errors A review of the organisational record of medication errors found no reports of medication errors involving consumers in the shared care program or in the sample during the study period from July 2003 to December 2004. Conclusion The low rate of sentinel events is evidence that the collaborative care arrangement has been provided in a safe manner. Appropriateness Of Care - Indicators Of Positive Consumer Outcomes The ECCMH project gathered data on positive consumer outcomes using questionnaires that were administered to three stakeholders (consumers, carers and General Practitioners) covering two topics about appropriateness of care (standards of care, and overall satisfaction). In addition progress through the pathway of care is reported. i Stakeholder ratings on standards of care Questionnaires gathered data on ratings from each stakeholder group on the standard of care. No definitions of standard of care were provided, so ratings reflect subjective views of stakeholders. An analysis of questionnaire results showed that consumers gave a mean rating of 2.9 on the scale for Standards of Care, with the two Aboriginal consumers giving a mean rating of 3.5. A rating of 2 is acceptable and 3 is good reasonable service. There was some comment that consumers were not informed about results of tests. Carers gave a mean rating of 2.6 on the scale for standards of care. One comment made was that the standard of care is ok when it is available. General Practitioners gave a mean rating of 3.1 on the scale for standards of care. Key workers gave a mean rating of 4.0 for standards of care. The rank order of stakeholders from highest to lowest ratings is: key workers, Aboriginal consumers, General Practitioners, consumers, and carers. ii Stakeholder rating of overall satisfaction The questionnaire asked for ratings of Overall satisfaction with service. This phrase was not defined. Consumers gave a mean rating of 3.2 for overall satisfaction, with Aboriginal consumers giving a mean rating of 3.5. Overall, 73.4% of consumers would recommend collaborative care to other consumers.
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Carers gave a mean rating of 1.9 for overall satisfaction. One comment was that a lack of contact by key workers with carers is viewed as showing a lack of trust towards carers by the mental health service. General Practitioners gave a mean rating of 3.1 for overall satisfaction. General practitioners gave the same rating of 3.0 to the capacity of collaborative care to maintain both physical health and mental health. 90% of general practitioner would recommend collaborative care to other consumers. Comments indicate that general practitioners view collaborative care as keeping patients in some degree of a support network. Key workers gave an overall rating of 2.7 for overall satisfaction, while raising a number of issues for further attention. In conclusion, ratings given by all stakeholders of both standard of care and overall satisfaction are positive. The rank order from highest to lowest was: Aboriginal consumers, other consumers, General Practitioners, key workers, and carers. iii Progress through pathway of care An analysis was made of movement of consumers between phases of care from the formal commencement of the project in July 2003 and 18 months later in December 2004. Table 6 shows movement between phases of care from 2003 to 2004 by giving the numbers of consumers from the sample of 60 in each phase of care at two time periods. Table 6 is most easily understood by reading from left to right in each row, as movement towards the right on the table represents progression into a less intensive form of care.
Table 6. Movement of consumers between phases of care from 2003 to 2004
SUM in 2004 Specialist in 2004 Shared Care in 2004 Consultancy in 2004 GP Care in 2004 Other in 2004
Specialist in 2003 Shared Care in 2003 Consultancy in 2003 SUM
26 27 7 60
14 3
7 19
1 1 4
3 3 3 9
1 1
17
26
Table 6 shows that of the 26 consumers in specialist care in 2003, 14 consumers remained in specialist care, and 11 moved into less intensive forms of care by 2004 being 7 in shared care, 1 in consultancy, and 3 to General Practitioner care. Of the 27 consumers receiving shared care in 2003, 19 continued to receive shared care in 2004, 1 moved to consultancy, and 3 moved to General Practitioner care. Three consumers moved into the more intensive specialist care.
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Of the seven consumers receiving a consultancy service in 2003, four remained in the consultancy phase, and three moved to General Practitioner care by 2004. Overall Table 6 shows steady if slow progression from each phase of care into less intensive phases of care. To analyze the results in a different way, Table 6 shows that: 37 consumers (62%) remained in the same phase of care 18 consumers (30%) moved into a less intensive phase of care 3 consumers (5%) moved into a more intensive phase of care
Table 6 shows that in 2004 34 consumers were in one of the forms of joint care with a General Practitioner (either shared care or consultancy), giving 57% of consumers in joint care with a General Practitioner. Of the two consumers listed as other, one consumer transferred to the MAC team and one moved to another region. Movement and perceived barriers An analysis was made of relations between phases of care in 2004 and perceived barriers to consumers moving into less intensive forms of care. This analysis showed that: Consumers receiving Clozapine were in both specialist care and shared care Consumers who had been on a CTO were in specialist care, shared care, and General Practitioner care Consumers on an administration order were in specialist care and shared care Consumers receiving disability support were in all four phases of care These data show that perceived barriers did not prevent consumers from progressing through phases of care into joint care with their General Practitioner. Qualitative statements by key workers in the Shared Care program indicate that some key workers were cautious about progressing consumers into the new phases of care. One key worker commented, It looks bad if a consumer has a crisis after you have moved the consumer on. It looks as if you are not doing your work properly. We have to avoid consumers becoming distressed. Another staff commented, What if a consumer was discharged and then was referred back? This would look like we had a revolving door service. Effectiveness Of Care Effectiveness of care refers to the extent to which care produces expected health benefits, and reduces the need for alternative unplanned types of care. NOCC
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scales have been accepted in Australia as the primary measure of outcome for mental health care. The ECCMH project team worked on an assumption that the Emergency Department of the hospital, the inpatient ward, and other parts of the mental health service are support services for community consumers that are available to be used in appropriate circumstances, but whose use is to be minimized. An analysis was made of the rate of use of other mental health services. i NOCC scores An analysis was made of relations between two scales used in NOCC (Health of the nation scale HoNOS, and Life skills profile LSP) and phases of care for those consumers where data were available, as shown in Table 7.
Table 7. Relation between phases of care and NOCC scores. Phase of Care HoNOS LSP N consumers Mean score N consumers Mean score Specialist 7 11.7 7 14.2 Shared 17 10.6 16 13.4 Consultancy 2 12.5 2 12 General practitioner care 1 13 0 SUM 27 11.9 25
A visual examination of HONOS scores shown in Table 7 does not suggest any trend for scores to change as consumers move between phases of care. Similarly a visual examination of LSP scores does not suggest any trend associated with phases of care. NOCC scores can be compared to scores reported in literature. Trauer et al (1999) analyzed HoNOS scores for 2137 consumers registered in community services in Victoria. They classified scores from 0-7 as being low, from 8-13 as being medium, and from 14-40 as being high. The mean score for people with schizophrenia was 10.6, for people with depression was 11.05, and for bipolar disorder was 9.1. By this standard, HoNOS scores of consumers in the sample reflect a medium level of difficulty. Table 7 does not indicate any relation between mean scores on either the HoNOS or LSP measures and phases of care. ii Focus of care Table 8 shows an analysis of relations between phases of care and focus of care as reported in the NOCC system for 27 consumers.
Table 8. Numbers of consumers in each NOCC focus of care FOCUS OF CARE NUMBER OF CONSUMERS 1 Acute care 7 2 Functional gain 2 3 Intensive extended 0 4 Maintenance 18 SUM 27
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Table 8 shows that the majority of consumers were classified in the maintenance focus of care in the NOCC system. The maintenance category is for consumers who have stabilised and function relatively independently and where the aim is to maintain level of functioning, and to minimise deterioration and to prevent relapse. The maintenance category is consistent with the aim of the Shared Care program. Seven consumers were classified as requiring acute care, aiming at a shortterm reduction in severity of symptoms and/or personal distress associated with recent onset or exacerbation of psychiatric disorder. The Shared Care program is expected to be able to manage brief crisis presentations from consumers registered in the program. Two consumers were classified as receiving a functional gain service that aims to improve personal, social or occupational functioning or to promote psychosocial adaptation in a patient with impairment arising from a psychiatric disorder. The Shared Care program is expected to have some capacity to provide basic skills training for registered consumers. In conclusion, the focus of care profile suggests that consumers in the Shared Care program largely coincide with category 4 in the NOCC system of Focus of Care. This accords with the goal of the Shared Care program. iii - Admissions to Emergency Department The Shared care program aims to maintain the stability of consumers and to minimize use of emergency services. The NHS Information System Service provided data about presentations by individuals in the sample to the Emergency Department of the local Noarlunga hospital for three time periods: 12 months prior to the study period - 1 July 2002 to 30 June 2003 12 month change period from 1 July 2003 to 30 June 2004 6 month follow up period from 1 July 2004 to 31 December 2004
While there is another hospital, Flinders Medical Centre, in the overall region the project was not easily able to obtain information about presentations to the emergency department of that hospital. Table 9 shows both numbers of presentations and rate of presentations per year per 100 consumers for each time period. Data are given for both presentations to ED and over-night stays in ED.
Table 9. Presentations to Emergency Department each year July 2002 to July 2003 to June 2003 June 2004 Number in ED 15 14 Rate 25 23 Number of overnight 4 1 stays in ED July 2004 to Dec 2004 3 10 1
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Table 9 shows that in the first time period (July 2002 to June 2003), 15 of the 60 consumers attended the Noarlunga Emergency Department, and 4 were admitted for an overnight stay. The numbers of consumers attending the emergency department and being admitted for an overnight stay reduced to 3 and 1 respectively in the third time period (July 2004 to December 2004). In terms of rate of presentations to ED, rate of presentations remained constant at about 25 presentations per hundred consumers per year from 2002 to June 2004, and reduced in the six month period from July-December 2004. No comparative data have been found for a similar consumer group to enable a comparison with established benchmarks. iv Admissions to local psychiatric inpatient unit The NHS Information System Service also provided data about admissions of individuals in the sample to the local psychiatric inpatient unit for the three time periods: 12 months prior to the study period from 1 July 2002 to 30 June 2003 12 month change period from 1 July 2003 to 30 June 2004 6 month follow up period from 1 July 2004 to 31 December 2004
Table 10. Admissions to psychiatric inpatient unit in each time period July 2002 to June 2003 9 15 July 2003 to June 2004 5 8.3 July 2004 to Dec 2004 1 3.3
Number of admissions Rate of admission
Admissions to a psychiatric unit are a measure of severity of relapse as a person requires treatment in a hospital setting. Data are converted to a rate of admissions where rate is the number of admissions per year per one hundred consumers in a group. Table 10 shows that rate of admission to the local psychiatric inpatient unit decreased steadily over time for consumers in the sample. A comparison can be made with bed days reported by Trauer et al (1999) for people who had comparable HoNOS scores. People in the sample reported by Trauer et al used 24.2 bed days per year. This study reports numbers of admissions which reflects on community services where Trauer et al (1999) reported bed days which also reflects on practices in inpatient units. v - Use of mental health services by discharged consumers An analysis was made of subsequent use of mental health services by consumers who were discharged from the Shared Care program to the care of their General Practitioner in the period July 2003 to June 2004. As only a few consumers from the sample were discharged, the analysis included consumers both from the sample and from the larger group of consumers in the Shared Care program. Follow-up was tracked for a minimum period of six months.
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The analysis focused on whether discharged consumers had received services from a local mental health service, and if so, which service. The number of consumers from the sample who were discharged to the care of their General Practitioner was 9 (15% of the sample). The study found that altogether 35 consumers were discharged from the Shared Care program to their General Practitioner during the study period. Numbers of consumers with each outcome are shown in Table 11. Percent is based on the total number of discharged consumers.
Table 11. Use of mental health services by discharged consumers UNIT RE-ADMITTED TO N Consumers Total number in sample of consumers Nil 6 24 1 community emergency contact 2 6 Return to Shared Care 1 3 Transfer to another region 2 9 35 Percent 69% 17% 9% 5% 100%
Table 11 shows that the majority of consumers who were referred to their general practitioner required no further follow up by mental health services. The next largest group contacted the emergency mental health service on one occasion. About 10% of consumers were re-admitted to the Shared Care program. Two consumers transferred to another region. Overall, discharged consumers made low use of mental health services in the period immediately following discharge. These figures can be contrasted with statistics about consumers who were discharged from the CCCC team in 1996-1997. Of the 342 consumers who were discharged in that period, 14% re-presented within a year and were re-registered with the team. RECOMMENDATION 8: That the Mental Health Division identifies rates of use of other mental health services that are considered to be appropriate based on information gathered in this project. Consumer Participation The topic of consumer participation is relevant both in terms of project management and in terms of individual consumers. i Participation by consumer representatives Consumer representatives were involved in the ECCMH project from the outset. The local consumer group that expressed concern about the impact of changes on quality of service delivery sought funds for the project following a representation. A nominee of the Noarlunga Consumer Advisory Group was on the project advisory group, as was a carer representative. The consumer representatives chaired some meetings.
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Both consumer and carer representatives participated in all meetings and focus group discussions that dealt with key aspects of the project, including preparation of questionnaires to evaluate the service. Additional consumers were involved in a focus group at the commencement of the project. Three consumers and a carer participated in interviewing other consumers in the evaluation phase, following training on the principles of objective interviewing. ii - Complaints One written complaint was received from a consumer in the sample. This consumer complained that when she was first diagnosed with a mental illness she had been informed by her then treating doctor that she would require medication for the rest of her life, and had been promised that she would never have to pay for her medication. The promise had been broken when the service asked her to go to her local pharmacy to collect medication, and was being continued by the approach of asking her to go to her general practitioner. The consumer thanked the project staff for listening to her complaint. iii Percent of consumers signing care plans One aim of the project was to enhance recovery and independent decisionmaking by consumers of the service. Consumer participation was assessed using two measures; percent of consumers signing care plans, and recording of early signs of relapse in the care plan as this reflects an emphasis on the selfmanagement approach. An analysis was made of the proportion of care plans that were signed by consumers, on the assumption that signing a care plan indicates participation in the decision making around treatment. There were 12 care plans filed in consumer medical records. Of these, all 12 were signed giving an overall percent of care plans that were signed by consumers of 20%. RECOMMENDATION 9: That the Mental Health Division endorse the use of joint care plans for routine communication with General Practitioners, and endorse the practice of asking consumers to sign care plans. iv Record of early warning signs in care plan An analysis was made of the percent of joint care plans in the file that included the consumers early warning signs of relapse, on the assumption that identification of early warning signs of relapse indicated that the service was promoting consumer independence in self managing their illness. This analysis found recorded early warning signs in 4 joint care plans, representing 7% of the sample.
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The low rate of recording early warning signs in joint care plans reflects some difficulty that requires further attention, and is addressed as a recommendation. RECOMMENDATION 10: That the Mental Health Division endorses the practice of recording early warning signs of relapse in joint care plans. Access The criterion of access to a service indicates that access should be based solely on consumer need and should occur irrespective of other considerations. Access is more difficult to define for this mental health program, as the program is accessible only to people who have been referred by another part of the mental health service. i Participation in collaborative care arrangement Of the 60 consumers first invited to participate in the new form of service delivery involving collaborative care and evaluation, 55 accepted and 5 declined, giving a participation rate of 92%. No consumer subsequently asked to leave the collaborative care arrangement, giving a zero attrition rate. The high rate of participation in the new collaborative care arrangement is viewed as reflecting a general acceptance by consumers of the new model of collaborative care. Consumers who were invited to participate in the collaborative care arrangement were existing consumers of the community mental health service. The profile of consumers in the sample in terms of demographic variables of age, gender, and race is shown in Table 1. The demographic profile appears similar to the population profile given in the Social Atlas for the City of Onkaparinga (1996). The sample included 5% Aboriginal consumers compared to about 1% in the Onkaparinga population. The sample included 1.6% people from an Asian background, compared to 0.6% in the Onkaparinga region. ii Number of consumers receiving a collaborative care service The numbers of consumers receiving a service from the Shared Care program during the time of the ECCMH project are shown in Table 12.
Table 12. Numbers of consumers over time Time July 2003 December 2003 July 2004 December 2004 Number of Registered Consumers 123 156 161 171
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Table 12 shows that the number of consumers registered in the Shared Care program increased by about 40% from July 2003 to December 2004. The number of referrals to the Shared Care program during 2004 averaged 5.8 per month. In December 2004 171 consumers were supported by the equivalent of 5 fte key workers, giving an average caseload for a full time worker of 34.2. It is concluded that the introduction of the collaborative care arrangement has produced a noticeable increase in number of consumers supported by the Shared Care program. Caseloads have exceeded the level that is supported in literature. iii Proportion of Consumers with a Nominated General Practitioner A criterion for nomination into the collaborative care project was that consumers were able to nominate a General Practitioner as their usual treating doctor. Consumers who could not nominate a General Practitioner remained in the usual Shared Care program. An analysis was made of 59 non-sample consumers in the Shared Care program to determine the number who had a nominated General Practitioner. The analysis found that 53 of these consumers had a nominated General Practitioner or Private Psychiatrist, and that 6 consumers had no nominated doctor, showing that 90% of these consumers had a nominated doctor. The high proportion of consumers with a nominated General Practitioner shows that it is viable to continue to develop collaborative care work jointly with General Practitioners. vi Percent of consumers in each phase of care An analysis was made of the proportion of consumers in the sample who were in each phase of care. There was special interest in the proportion of consumers in the two phases involving joint care with a General Practitioner (shared care and consultancy phases) as this measure assesses the success of a program that has a goal of encouraging collaborative work with General Practitioners. Table 13 shows the numbers and percentages of consumers in each phase of care in two time periods, in July 2003 when cycle 2 formally commenced and in December 2004.
Table 13. Numbers of consumers in each phase in two time periods July 2003 December 2004 Phase of Care N of N of consumers Percent consumers Percent Specialist care 26 43% 17 28% Shared care 27 45% 26 43% Consultancy 7 12% 6 10% General Practitioner care 0 0 9 15% Other 0 2 3% Sum 60 100% 60 100%
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Table 13 shows that in 2003 consumers were concentrated in two phases of care, specialist care and shared care. There has been an overall movement of consumers from specialist care into other phases of care. In December 2004 there were 26 consumers in the shared care phase (43% of the sample) and 6 consumers in the consultancy phase (10% of the sample), giving an overall figure of 53% of consumers in 2004 in a joint care arrangement with a general practitioner (shared care and consultancy). The Shared Care program has adopted a goal of having caseloads of 30 consumers with 25 consumers receiving active care and 5 consumers being in the consultancy phase of care, so that 16.6% of consumers are in the consultancy phase. Against this standard, in December 2004 there were 43 consumers receiving active care and a further 6 consumers receiving a consultancy service, giving an overall figure of 12% of consumers being in a consultancy phase compared to the goal of 16% of consumers. v Involvement of Aboriginal consumers Of the 60 consumers in the collaborative care sample, three were identified as Aboriginal, and two of these participated in the evaluation. Ratings given by Aboriginal consumers are similar to ratings given by other consumers, being higher on some topics and lower on other topics. Topics that received higher ratings were standards of care and reimbursement. Topics that received lower ratings were communication, working together, and sharing of information. iv Consumers with other disabilities An analysis was made of whether consumers in the sample had other disabilities apart from disability due to mental illness. One consumer had a brain injury. Seven consumers were listed as having a personality disorder. Efficiency Of Care Efficiency of care refers to whether resources are used in a cost-effective way. Efficiency of the new system of collaborative care is assessed in terms of numbers of contacts made in each phase of care. i Numbers of contacts in each phase of care To assess the impact of the new model of care on workload of mental health staff, an analysis was made of the numbers of contacts recorded by mental health staff in the CMS data recording system for consumers in each phase of care. The analysis separates contacts by key workers and contacts by doctors of the clinic. The analysis is based on categorisations of consumers into phases of care made in December 2004.
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Table 14 shows mean numbers of contacts per year made by both key workers and clinic doctors for consumers in each phase of care. Ratio is the ratio of key worker/doctor contacts. To enable a comparison, contact figures are also shown for 59 consumers of the Shared Care program who were not included in the sample. Table 14 shows the pattern of contacts by staff of the mental health service as consumers move between phases of care. Overall, key workers have more contacts with consumers than doctors in all phases of care as shown in the Ratio column. There is a considerable range in numbers of contacts in each phase of care for both key workers and doctors. Table 14 shows that key workers contacted consumers in specialist care on about a weekly basis (52 times per year), while clinic doctors contacted these consumers about every six weeks (8.6 times per year). As consumers moved into shared care, key workers reduced their contacts to about every ten days, while doctors maintained about the same level of contacts. As consumers moved into the consultancy phase, key workers maintained contacts at about a fortnightly basis, while doctors reduced the frequency of their contacts to every six months. The non-sample group is not differentiated according to phases of care. The mean figures for the non-sample group shows that these consumers were contacted about weekly by their key workers, and about every ten weeks by their doctor. As the range in contacts in each phase of care is high, a brief analysis was made of factors associated with variations in each phase of care. One consumer received a high number of contacts from a key worker in the specialist phase of care. This consumer was on both a CTO and an administration order. Three consumers received high numbers of contacts in shared care.
Qualitative statements by key workers indicate that some staff gauge their own functioning in part by keeping themselves busy and by seeing consumers frequently so as to keep their contacts high. One staff commented, I do not use the phases of care. I just respond to consumers needs and see the consumer when I need to.
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Table 14. Numbers of contacts in each phase of care for sample consumers PHASE OF CARE Number of Key worker Doctor Ratio consumers contacts per contacts per year year Specialist Care 17 Mean 55.5 7.8 7.1 Range 6 - 132 3 15 Shared Care 26 Mean 35.7 8.2 4.4 Range 1 73 0 15 Consultancy 6 Mean 31 2.2 14.0 Range 0 56 09 General Practitioner 9 care Transferred 2 SUM 60 NON SAMPLE 59 44.8 5.3
In its draft Service Plan, the Shared Care program aims to decrease levels of input by key workers as consumers move through the phases of care. Table 14 shows there is scope to reduce numbers of contacts by mental health staff especially in the phases of shared care and consultancy. Trauer et al (1999) reported that a sample of consumers with comparable HoNOS scores received 84 contacts per year. Trauer et al also found no association between frequency of contact and improvement on HoNOS scores. A proposed average frequency of contact per year for consumers in each phase of care is given in Table 15.
Table 15. Proposed frequency of contact for consumers in each phase of care PHASE Key worker contacts per year 52 26 12 2 Doctor contacts per year 8-12 3-6 2 1 General practitioner contacts per year 12 12 12
Specialist care Shared care Consultancy General practitioner care
RECOMMENDATION 11: That the Division of Mental Health state an expected frequency of contact with consumers in each phase of care. v - Reimbursement for General Practitioners The topic of reimbursement for General Practitioners was examined in the stakeholder questionnaires.
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The survey found that 40% of General Practitioner in the sample had claimed EPC items to reimburse their time spent in collaborative care. The independent evaluator reports that, despite receiving good average ratings, dichotomous answers were given by all stakeholders about use of EPC items to reimburse General Practitioner depending on whether the General Practitioner bulk-billed or charged a gap payment. When General Practitioners bulk-billed, ratings of very high were given. When General Practitioners did not bulk-bill, ratings of very poor were given. General Practitioners gave dichotomous ratings when they were asked to indicate their satisfaction with EPC items for reimbursement. One doctor reported that EPC items do not compensate for time spent planning for patients who then do not keep appointments. When asked whether finance was a factor in deciding whether to participate with mental health consumers, 70% of General Practitioners responded No. One doctor responded that the low financial return does not encourage General Practitioners to take on new consumers who have complex needs. There are further reports that it is difficult for General Practitioners to both spend time on care plans and see sufficient consumers to earn bonuses for bulk billing. A number of General Practitioners recognised that many mental health consumers were not in a position to pay gap fees. Evaluation of Partnership Processes An independent evaluator who prepared a report that is available from the project officer. The independent evaluator organized data collection using the questionnaires, both conducted interviews and over-sighted interviews that were conducted by nominated consumer and carer interviewers, and carried out all data analysis. The independent evaluator gathered data from General Practitioners, from nongovernment agencies, and from staff of the mental health service. Consumer and carer representatives gathered data from people they represented. Response Rate The independent evaluator approached 60 consumers and invited them to participate in the new system of collaborative care, and also to participate in the evaluation. Of the 60 consumers approached by the independent evaluator, 28 consumers agreed to participate in the evaluation giving a response rate of 47%. These consumers nominated 18 General Practitioners, 10 of whom completed the questionnaire giving a response rate of 55.6%. Consumers nominated 15 carers and all participated in the evaluation giving a response rate of 100%. Seven mental health staff who had been involved in service delivery during the study
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period were available to be interviewed, including 5 key workers, a team leader and consultant psychiatrist. Three non-government agencies that provided disability support services to consumers were approached and provided feedback. Two Aboriginal consumers participated in the evaluation, and their ratings are presented separately from other consumer data. Questionnaire Results The report of the independent evaluator passed on a number of positive comments from stakeholders showing an overall positive attitude towards the collaborative care project from all stakeholders. Positive comments that are highlighted on page 37 of the independent evaluation are: Health professionals are respectful when communicating with consumers, carers and NGOs The community liaison by key workers has improved greatly High levels of consumer confidence in the abilities of General Practitioners and Adaire staff High levels of general practitioner and key worker confidence that they will be able to deal with issues raised by consumers Good satisfaction with the collaborative care arrangement to enable the maintenance of both mental and physical health of consumers The independent evaluation report identified five topics as requiring more attention (pages 37 and 31) involving: Care plan, as the joint care plan has not been widely adopted as the primary method of clinical communication, with phone contact and face-to-face meetings being used more commonly Resources, with time constraints of General Practitioners and key workers being raised as one of the greatest impediments to collaborative care Structure of the phases of care, with phases of care not being defined sufficiently clearly, and with no ongoing education for new staff. (Definitions were improved in phase 3 of the project). Payments, with satisfaction when the general practitioner bulk bills but dissatisfaction when a general practitioner charges a gap payment Management support around issues of risk, with insufficient clarity on some points
Summary results from the independent evaluation report are given in Table 16 in terms of mean scores given by each stakeholder group on each topic. The independent evaluator added the topic program structure after receiving comments.
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Table 16. Mean ratings by stakeholder groups on all scales Overall Results Consumers Carers N of 28 Communication Working together Standards of care Joint care plan instrument Programme structures Confidence Sharing of information Payments / reimbursement Overall satisfaction 2.9 3.3 2.9 1.0 X 3.2 3.2 3.1 3.2 Aboriginal (2) 2.5 2.3 3.5 2.0 X 3.5 2.3 4.5 3.5 N of 15 2.1 2.4 2.6 0.4 X 2.6 1.8 3.1 1.9
GP N of 18 2.8 3.0 3.1 2.7 X 3.2 3.0 2.2 3.1
MH staff N of 7 2.9 3.3 4.0 2.8 1.9 2.9 X X 2.7
Mean scores are interpreted using a criterion that scores of 2 or more on the scale from 0-5 reflect a general satisfaction with a topic, whereas mean scores from any stakeholder group below 2 reflects dissatisfaction that warrants closer investigation. A score of 2 on the scale was labeled as acceptable. The two Aboriginal consumers gave ratings that are generally similar to ratings given by other consumers (pg 78). All stakeholder groups gave generally satisfactory ratings for six of the eight specific topics and for overall satisfaction. The six specific topics are: communication, working together, standards of care, confidence, sharing of information, and payments. Overall, carers gave lower ratings than other stakeholder groups on all topics. Low ratings were given by all stakeholder groups to the topics Joint care plan instrument and program structure. Qualitative comments gathered by the independent evaluator shows that the low rating for the joint care plan instrument reflects a low uptake by key workers in using joint care plans to record clinical planning with General Practitioners. Qualitative comments recorded by the independent evaluator also indicates a need to conduct further work on the detailed definitions of each phase of care in the model of collaborative care, and to provide operational definitions to indicate when consumers are ready to progress to the next phase of care, and to state the duty of care in each phase more clearly. RECOMMENDATION 12: That the Division of Mental Health further investigate issues around the satisfaction of carers with service delivery.
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Communication Using Preferred Care Plan Instrument An audit was conducted of files of consumers in the sample to identify types of written communication between the mental health service and general practitioner, focusing on use of the recommended joint care plan, and letters from the mental health service. A copy of the audit form is included in appendix 6. The audit found joint care plans in 12 of the 60 files representing 20% of the sample. There were letters in a further 33 files, showing written communication in 77% of cases. The audit found that all files contained community management plans, which are the traditional record, used in community mental health services. The low use of joint care plans is a point of concern and may highlight a deficiency in the method of approaching General Practitioners to transfer care. It is recommended that a new format for transferring care of a consumer to a General Practitioner be used that provides more information to the General Practitioner, along the lines of the Transfer of Care form used in the CLIPP program as outlined on page 62 of this report. RECOMMENDATION 13: That the Division of Mental Health promote the use of the joint care plan as the primary method of communication with General Practitioners in collaborative care arrangements. RECOMMENDATION 14: That the Division of Mental Health review the measures used in this report and select some measures for ongoing use for continuous quality improvement purposes.
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COLLABORATIVE CARE IN MENTAL HEALTH IN NOARLUNGA QUALITATIVE REPORTS

Three further topics are discussed on the basis of qualitative feedback from participants involving: Ability to provide each form of service Sustainability Risk management.
Ability to Provide each Form of Service The new collaborative care model is based on four phases of care, of which two are traditional and two are new. One issue involves the capacity of the mental health service to provide services that are proposed in the new model of collaborative care. The mental health service was able to provide the traditional specialist care. Following training, key workers in the Shared Care program appeared able to provide the services required in the shared care phase of the new model. Training was required on topics including the rationale for the model of care, the philosophy underlying the model of care, and skills in approaching General Practitioners and preparing joint care plans. It was hoped that the skills and attitudes required to implement collaborative care arrangements might be passed on using a combination of formal presentations and coaching from a more experienced member of staff. Key workers in the Shared Care program were also able to provide a consultancy service to General Practitioners in the initial period after care of a consumer was transferred to the General Practitioner, while the information available to the key worker was still current. Key workers in the Shared Care program experienced greater difficulty in providing an ongoing consultancy service that extended for some years after care of the consumer had been transferred to the General Practitioner. More work is required both to develop a model of ongoing consultancy, and to clarify which part of the mental health service is best suited to provide this form of care. RECOMMENDATION 15: That the Division of Mental Health further develop practices required in a consultancy service. Training for Sustainability The ECCMH project identified a need for ongoing training of mental health professionals if gains made in the project are to become embedded and sustained.
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It is recommended that there be ongoing staff training for mental health key workers, doctors in the mental health service and General Practitioners on the following topics: The model of collaborative care based on phases of care, and the philosophy of care including attitudinal issues The joint care plan as the primary tool for clinical communication with General Practitioners Sample cases
RECOMMENDATION 16: That the Division of Mental Health use materials outlined in this report to form the basis of staff development materials to promote the sustainability of initiatives in collaborative care. Risk Management Analyses As discussed above, some stakeholders in the ECCMH project perceived a tension between demand to provide care for more consumers and quality of care provided to existing consumers. There was also concern that a change towards a partnership model of collaborative care might reduce quality of care. The ECCMH project discussed a number of variables associated with risks to quality of care. One traditional approach for managing risk in community health is to focus on issues at the level of individual consumers. For example, root cause analyses are conducted over individual cases where an adverse event has occurred. Another approach for developing informed attitudes about risk issues focuses on overall or aggregate relations between two objective variables. A quantitative analysis can be made of how change in one variable of interest affects another variable of interest. An analysis of risk associated with change can be conducted using a graph where a risk variable (a negative variable whose occurrence is to be minimised) is displayed against a positive variable that is to be maximised. Use of a risk-analysis graph allows managers to discuss the level of risk that is acceptable as a dependent variable is changed. It is proposed that it is preferable for managers to set risk standards for a service instead of leaving individual clinicians to set standards that reflect personal risk-attitudes. For example, a staff member may set a zero tolerance attitude towards clients presenting to the emergency department of the hospital and may spend a great deal of time trying to avoid all presentations to an emergency department, viewing any presentation to the ED as an event that is unacceptable and deserves criticism. An attempt to maintain a zero rate of presentation to ED may result in an over-concentration of resources on a few clients when a crisis management plan would achieve similar outcomes. The ECCMH project discussed but did not resolve the question of how best to identify risk-attitudes that are sustainable for a service.
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The Australian Council on Healthcare Standards (2003) recommend in the Clinical Indicator User Manual that quality of care be measured in terms of variables with negative connotations including adverse reactions to a medication, unplanned readmissions to a hospital, and mortality. This project distinguished between measures of positive clinical functioning that are to be maximised and risk variables (adverse sentinel events) that are to be minimised. Use of a graphical risk analysis would enable rate of positive clinical functioning to be plotted against rate of adverse sentinel events when a third variable (such as rate of registration) is varied. RECOMMENDATION 17: That the Division of Mental Health continue to discuss risk attitudes that are appropriate in a community mental health service.
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ACHIEVEMENTS OF THE PROJECT

The project made significant progress towards achieving each of the four goals of the project as summarised below. Goal 1 To improve integration Integration between community mental health services and General Practitioners was improved by introducing a new conceptual model of collaborative service delivery that promotes continuity of care based on four phases of care that consumers can move through in an orderly manner. The collaborative model of care replaced a model with two phases where consumers were managed either by a mental health key worker or by the General Practitioner by introducing two intermediate phases of care. The model of collaborative care is broad enough to cover issues that are raised by a diverse group of consumers who presented with reasonably complex needs. The model of care promotes movement through the mental health system by identifying phases of care where General Practitioners and mental health staff make differing contributions to consumer care. Phases in the model make use of the identified strengths of each stakeholder group, and are made available to consumers according to assessed needs of consumers. The new model of collaborative care makes better use of very limited resources in a region where demand for services is very high. Communication between mental health staff and General Practitioners was improved by identifying a joint multi-disciplinary care plan as the primary method of clinical communication. Goal 2 Sustainability of Changes The following steps enhance sustainability of change: General Practitioners have been introduced to the use of EPC items to reimburse their participation in collaborative care, including participation in joint care planning. A range of measures have been clarified that can be used in an ongoing quality assurance process
The project identified nine factors that were considered to be critical to the success of a collaborative care partnership, implemented these factors, and obtained feedback from stakeholders on the factors in the evaluation. The nine proposed critical success factors are: communication, working together, standards of care, communication instruments, confidence, sharing of information, reimbursement and resources, having a clear model of care, and overall satisfaction with service delivery.
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Goal 3 Improve Communication Communication between the Division of General Practice and the Mental Health Division has improved at two levels: Clinical communication has improved in interactions over individual consumers following the identification of an agreed instrument for care planning, and implementation of an agreed process for liaison Administrative communication has improved due to two processes, regular meetings between representatives of both divisions, and efforts of the general practitioner liaison officer
Goal 4 Extend Partnership to Other Agencies The collaborative care partnership was developed between mental health staff and General Practitioners. Within the project the partnership was extended to those nongovernment agencies that provided disability support to consumers in the project. There have been requests to extend the collaborative care partnership approach to further government health and welfare agencies. Outcomes The project has achieved progress on the following outcomes. A new system of collaborative care has been identified and introduced that provides for joint or simultaneous work between General Practitioners in defined phases of care The new system of care was evaluated using a set of questionnaires that were designed by consumers, carers and General Practitioners The pathway for General Practitioners to communicate with the mental health service regarding consumers registered in the Shared care program has been clarified The model of care is documented in terms of care plans, protocols for some areas of practice and an audit tool The new model of care has the potential to be generalized to other groups of consumers and to other mental health services Measures have been identified that can be used in ongoing quality assurance processes There are plans to disseminate information about the new model of care in a variety of ways to different interest groups
Informed Risk Management The project recommends an approach for producing informed risk attitudes in community mental health. Risk analyses can be conducted using a graphical approach using objective measures where an outcome measure that is to be maximized is plotted against a risk variable that is to be minimized.
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What Worked Well The success of the project is attributed to the following factors: Funds were used to change and to re-design the system of care, rather than to employ a specialist liaison worker or to concentrate on the skills of a small specialist group of General Practitioners The steering committee was representative of stakeholders who were willing to problem-solve around difficult issues Both consumer and carer representatives participated fully in discussions in the steering committee The Liaison Officer with the Division of General Practice was able to organize focus groups of General Practitioners to provide feedback to the steering committee The project used a strengths approach by focusing on areas of good practice and extending these, rather than by concentrating on areas of greatest difficulty Mental health staff demonstrated a willingness to work in different ways The project introduced delineations of responsibilities in models of practice, based on assessed strengths of participants The new model of care was offered to all General Practitioners who were nominated by consumers as their treating doctor Senior managers supported the aims of the project The local inpatient unit had set a tone of working closely with General Practitioners by sending discharge summaries to General Practitioners promptly on discharge
Future Tasks The ECCMH project identified a number of areas where further work could usefully be carried out. To further embed practices, additional work could be conducted within the main focus area of the project, including: Clarifying operational definitions of phases in the model of care Further clarification of new phases of care, especially the consultancy phase Introduce ongoing staff training both for new mental health key workers and for General Practitioners
Key performance measures can be used in an ongoing way, leading to further examination of appropriate risk-attitudes towards consumers. The model of collaborative care can be extended to further groups of consumers.
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COLLABORATIVE CARE IN MENTAL HEALTH IN NOARLUNGA REFERENCES

Abidi, S., & Bhaskara, S.M. (2003). From chlorpromazine to Clozapine antipsychotic adverse effects and the clinicians dilemma. Canadian Journal of Psychiatry, 48, 749755. ACHS Performance and outcomes service. (2003). Mental health indicators. American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, and North American Association for the Study of Obesity. (2004). Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care, 27, 596-601. Andrews, G., Peters, L., & Teesson, M. 1994. The measurement of consumer outcomes in mental health. A report to the national mental health information strategy committee. Clinical Research Unit for Anxiety Disorders, Sydney. Anthony, W.A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16, 11-13. Bebbington, P., Brugha, T., Hill, T., Marsden, L., & Window, S. (1999). Validation of the Health of the Nation Outcome Scales. British Journal of Psychiatry, 174, 389-394. Betts, V.T. & Thornicroft, G. (2001). International mid-term review of the second national mental health plan for Australia. Mental Health and Special Programs Branch, Department of Health and Ageing, Canberra. Brophy, L., & McDermott, F. (2003). Whats driving involuntary treatment in the community? The social, policy, legal and ethical context. Australasian Psychiatry, 11, 84-88. Burns, T. (1997). Psychosocial interventions. Current opinion in psychiatry, 10, 36-39. Callaly, T., & Hallbone, E.L. (2001). Introducing the routine use of outcome measurement to mental health services. Australian Health Review, 24, 43-50. Canadian Journal of Psychiatry, May 2002. Vol 47, No 2, Supplement 1.Shared mental health care: A bibliography and overview. CAMH best advice paper. Community treatment orders: overview and recommendations. (2001). Centre for Addiction and Mental Health, Canada. Citrome, L.L., & Jaffe, A.B. (2003). Relationship of atypical antipsychotics with development of diabetes mellitus. The Annals of Pharmacology, 37, 1849-1857. Code of fair information practice. (2002). South Australia: Department of Human Services. Coglan, R., Lawrence, D., Holman, C.D.J. & Jablensky, A.V. (2001). Duty of Care: Physical Health in People with Mental Illness. Perth, The University of Western Australia.
93

Copeland, M.A. 2002. Wellness recovery action plan. Peach Press. Vermont. Department of Human Services (2003). Privacy and your personal information. Adelaide. Donabedian, A. (1988). The quality of care: How can it be assessed? Journal of the American Medical Association, 260, 1743-1748. Druss, B.G., Rosenheck, R.A., & Stolar, M. (1999). Patient satisfaction and administrative measures as indicators of the quality of mental health care. Psychiatric Services, 50, 1053-1058. Evaluation of the second national mental health plan (2002). Mental health and suicide prevention branch, Commonwealth Department of Health and Ageing, Canberra. Falloon, I.R.H., Boyd, J.L., & McGill, C.W. (1984). Family care of schizophrenia. New York: Guilford Press. Fennema, H., & Wakker, P. (1997). Original and cumulative prospect theory: a discussion of empirical differences. Journal of Behavioral Decision Making, 10, 53-60. Fowler, D., Garety, P., & Kuipers, E. (1995). Cognitive behaviour therapy for psychosis. Chichester: Wiley. Garton, A. (1999). Psychology. In Learning together: Education and training partnerships in mental health, pp. 52-56. Deakin Human Services Australia. Department of Health and Aged Care, Canberra. Gilovich, T., Griffin, D., & Kahneman, D. (2002). Heuristics and biases: the psychology of intuitive judgment. Cambridge University Press, Cambridge. Gourney, K. (1996). Setting clinical standards of care in schizophrenia. Nursing Times, 92, 36-37. Gournay, K. (1997). Clinical effectiveness: what we need to do. Psychiatric Care, 4, 221-224. Gourney, K.J.M., & Brooking, J.I. (1994). The community psychiatric nurse in primary care: an outcome study. British Journal of Psychiatry, 165, 231-238. Harries, M. (1999). Social work. In Learning together: Education and training partnerships in mental health, pp. 57-62. Deakin Human Services Australia. Department of Health and Aged Care, Canberra. Hazelton, M. (1999). Mental health nursing. In Learning together: Education and training partnerships in mental health, pp. 33-38. Deakin Human Services Australia. Department of Health and Aged Care, Canberra. Hickie, I. B. (1999). Primary care psychiatry is not specialist psychiatry in general practice. Medical Journal of Australia, 170, 171-173.
94

Hickie, I. B., Davenport, T. A., Naismith, S. L., Scott, E. M., Hadzi-Pavlovic, D., & Koschera, A. (2001a). Treatment of common mental disorders in Australian general practice. Medical Journal of Australia, 175, 25-30. Hickie, I. B., Davenport, T. A., Naismith, S. L., & Scott, E. M. (2001b). Conclusions about the assessment and management of common mental disorders in Australian general practice. Medical Journal of Australia, 175, 52-55. Holmwood C. (1998). Mental Health Services and General Practice. Mental Health Matters, South Australian Mental Health Training and Support Network. Holmwood, C., Groom, G., & Nicholson, S. (2001). Mental health shared care in Australia 2001. Report for the Commonwealth Department of Health and Ageing. Primary Mental Health Care Australian Resource Centre, Department of General Practice, Flinders University, South Australia. I seru. (1997). From projects to programs. Sharing mental health care: A guide for Divisions of General Practice. Integration Support and Evaluation Resource Unit. Centre for General Practice Integration Studies, University of New South Wales, Sydney. Jaworowski, S., & Guneva, R. (2000). Integrating community treatment orders into best clinical practice. Australasian Psychiatry, 8, 59-62. Kanter, J. (1989). Clinical case management: definition, principles, components. Hospital and Community Psychiatry, 40, 361-368. Kavanagh, D. (1992). Recent developments in expressed emotion and schizophrenia. British Journal of Psychiatry, 160, 601-620. Kavanagh, D., Piatkowska, O., Manicavasagar, V., OHalloran, P., & Clark, D. (1991). Living with schizophrenia: a cognitive-behavioural intervention for individuals and families. Keks, N.A., Altson, B.M., Sacks, T.L, Hustig, H.H., & Tanaghow. A. Collaboration between general practice and community psychiatric services for people with chronic mental illness. Medical Journal of Australia Practice Essentials, 8-13. King, R., Le Bas, J., & Spooner, D. (2000). The impact of caseload on the personal efficacy of mental health case managers, Psychiatric Services, 51, 364-368. Kosky, R., Rosen, A., & Phillips, J. (1999). In Learning together: Education and training partnerships in mental health, pp. 44-51. Deakin Human Services Australia. Department of Health and Aged Care, Canberra. Kuipers, L., & Bebbington, P. (1988). Expressed emotion research in schizophrenia: theoretical and clinical implications. Psychological Medicine, 18, 893-909. Lean, M.E.J., & Pajonk, F.G. (2003). Patients on atypical antipsychotic drugs. Diabetes Care, 26, 1597-1605.
95

Lebovitz, H.E. (2003). Metabolic consequences of atypical antipsychotic drugs. Psychiatric Quarterly, 74, 277-290. Leff, J. (1994). Working with the families of schizophrenic patients. British Journal of Psychiatry, 164, 71-76. Lef, J., & Vaughn, C. (1985). Expressed emotion in families: its implications for mental illness. Guilford Press, New York. Liebzeit, K.A., Markowitz, J.S., & Caley, C.F. (2001). New onset diabetes and atypical antipsychotics. European Neuropsychopharmacology, 11, 25-32. Maas, F., & Foti, J. (2000). Consumer and carer satisfaction survey: Adult mental health services. AC Neilsen summary report. Department of Human Services, Victoria. Marder, S.R., Essock, S.M., Miller, A.L., Buchanan, R.W., Davis, J.M., Kane, J.M., Lieberman, J., & Schooler, N.R. (2002). The Mount Sinai conference on the pharmacotherapy of schizophrenia. Schizophrenia Bulletin, 28, 5-16. Marshall, M. (1996). Case management: a dubious practice. British Medical Journal, 33, 415-428. Marshall, M., Gray, A., Lockwood, A., & Green, R. (1996). Case management for severe mental disorders. In Schizophrenia module of the Cochrane database of systemic reviews (updated 27 February 1996). The Cochrane Library, BMJ Publishing Group. Marwick, M., Reece, M., & Battersby, M. (2003). The development and implementation of a generic assessment tool in chronic disease self-management. Health outcomes conference. Mazza, D., & Russell, S. (2000). Final report of a consultancy to develop an implementation strategy for evidence-based, best practice clinical practice guidelines for general practice in Australia. The Royal Australian College of General Practitioners. McGorry, P. D. (1992). The concept of recovery and secondary prevention in psychiatric disorders. Australian and New Zealand Journal of Psychiatry, 237, 3-17. McGowan, C. (2001). General practitioner/Mental Health in primary care planning day. Department of Human Services, Statewide Division, Mental Health Unit. Adelaide. McIvor, R. (1998). The community treatment order: clinical and ethical issues. Australian and New Zealand Journal of Psychiatry, 32, 223-228. Mead, S., & Copeland, M.E. 2000. What recovery means to us: Consumers perspectives. Community Mental Health Journal, 36, 315-328. Meadows, G. N. (1998). Establishing a collaborative service model for primary mental health care. Medical Journal of Australia, 168, 162-165.
96

Meadows, G. 2001. CLIPP (consultation and liaison in primary care psychiatry) manual. http://www.dhs.vic.gov.au/acmh/mh/clipp/transfers.htm Meadows. G. (2002). Consultation and liaison in primary care psychiatry. Linking general practitioner, hospital and community: ARCHI Toolkit seminar report. www.archi.net.au Meadows, G. N. (2003). Overcoming barriers to reintegration of patients with schizophrenia: developing a best-practice model for discharge from specialist care. EMJA, 178, 53-56. Mental Health Council of Australia (2000). Enhancing relationships between health professionals and consumers and carers Final report. Canberra, ACT. Commonwealth Department of Health and Aged Care. Mental health policy implementation guide: community mental health teams. (2001). Department of Health, Britain. MH-CIAO team. (2003). South Australian clinicians reference guide for the NOCC. Department of Human Services, Adelaide. Moss, J., Saunders, I., & Wilson, C. (2001). Outcome measures for community mental health services. Evidence Based Management Group, CSIRO Mathematical and Information Sciences, Adelaide. Mueser, K., Bond, G., & drake, R. (1995). Models of community care for severe mental illness: a review of research on case management. Schizophrenia Bulletin, 24, 37-74. National case management working group (1997). National practice principles in SAAP case management. Commonwealth Department of Health and Family Services, Commonwealth of Australia. National Mental Health Plan 2003-2008. Australian Health Ministers Nelson, K., Fowler, S., Cumming, J., Peterson, D., & Phillips, B. (2003). Evaluation of mental health/primary care shared services. Mental health research and development strategy. Health Research Council of New Zealand. Novartis. (2003). Clozaril shared-care program protocol. Novartis Pharmaceuticals Australia Pty Limited. North Ryde, NSW, Australia. OHagan, M. (2004). Recovery in New Zealand. Auseinet, 20, 1, 5-6. Olfson, M. (1990). Assertive community treatment: an evaluation of the experimental evidence. Hospital and Community Psychiatry, 41, 634-641. PARC (2002). Models of shared care and their effectiveness. Primary mental health care, Flinders University.
97

Pennebaker, D., Vogels, R., Browton, R., & Anderson, R. (2000). Consumer satisfaction in mental health services. Centre for Mental Health Services Research. Perth, Western Australia. Penrose-Wall, J. (1998). Mental health shared care: A review of projects 1993-1996. Integration Support Evaluation Resource Unit. School of Community Medicine, University of NSW. Penrose-Wall, J. (1998). If only mental health was as straightforward as diabetes. Mental Health Matters; South Australian Mental Health Training and Support Network. Penrose-Wall, J., & Harris, M. (2000). From woe to go: mental health clinical practice guidelines and general practice. The Centre for General Practice Integration Studies, School of Community Medicine, University of New South Wales, Sydney. Penrose-Hall, J., & Harris, M. (2000). From woe to go: Mental health practice guidelines and general practice. The Centre for General Practice Integration Studies, School of Community Medicine, The University of New South Wales, Sydney. PARC, Primary Mental Health Care Australian Resource center, (2001). Models of shared care.parc@flinders.edu.au Penrose-Wall, J. (1998). Mental health shared care: a review of projects 1993-1996. Integration support evaluation resource unit. Pirkis, J., Burgess, P., Kirk, P., Dodson, S., & Coombs, T. (2005). Review of standardized measures used in the National outcomes and casemix collection (NOCC). Australian Mental Health Outcomes and Classification Network. Canberra. Rafalowicz, E. (1997). From CCT to CCCCT. Southern Mental Health News. Rathjen, P.J. (2004). Evaluation of a community based intervention for the management of weight gain in patients on Clozapine a pilot study. Dissertation submitted to the Royal Australian and New Zealand College of Psychiatrists for Section 11 Fellowship examination. Adelaide. Rickwood, D. (2004). Pathways of recovery: preventing relapse. National mental health promotion and prevention working party, Department of Health and Ageing. Royal Australian College of General Practice (2000). Guide to prevention in general practice. Scotman, G. (2004). What is recovery? What are the current debates? Synergy, 3, 45. Sharma, V.K., Wilkinson, G., & Fear, S. (1999). Health of the nation outcome scales: a case study in general psychiatry. British Jornal of Psychiatry, 174, 395-398. Siegel, A.P., Astrachan, B.M., & Levine, M.S. (1984). Re-evaluating the work of a community mental health centre: the care of chronic patients. Hospital and Community Psychiatry, 35, 1129-1132.
98

Simmonds, S., Coid, J., Joseph, P., Marriott, S., & Tyrer, P. (2001). Community mental health management in severe mental illness: a systematic review. British Journal of Psychiatry, 178, 497-502. Social Atlas. (1996). City of Onkaparinga, Adelaide. Steedman, T., Yellowlees, P., Mellsop, G., Clarke, R., & Drake, S. 1997. Measuring consumer outcomes in mental health. A report to the Australian Health Ministers Advisory Council National Mental Health Working Group. Mental Health Branch, Commonwealth Department of Health and Family Services. Sternberg, R.J., & Ben-Zeev, T. (2001). Complex cognition: the psychology of human thought. Oxford University Press: Oxford. Swan, N. (2003). Mental health rehabilitation and recovery services for South Australia. Mental Health Services and Programs, Department of Human Services, Adelaide. Synergy (2004). Recovery. What is it? The magazine of multicultural mental health Australia, edition no 3. Parramatta, Sydney. Trauer, T., Callaly, T., & Hantz, P. (1999). The measurement of improvement during hospitalisation for acute psychiatric illness. Australian and new Zealand Journal of Psychiatry, 33, 379-384. Trauer, T., Callaly, T., Hantz, P., Little, J., Shields, R., & Smith, J. (1999). Health of the nation outcome scales: Results of the Victorian field trial. British Journal of Psychiatry, 174, 380-388. Tversky, A., & Koehler, D.J. (1994). Support theory: a nonextensional representation of subjective probability. Psychological Review, 101, 547-567. Urukalo, M. (2002). Chronic condition self-management education and training manual. Flinders University Coordinated Care Training Unit, Adelaide. Van Hoof, F., van Weeghel, J., & Kroon, H. (2000). Community care: exploring the priorities of consumers, mental health professionals and community providers. International Journal of Social Psychiatry, 43, 408-419. Webster, I., & Raphael, B. (2001). Evaluation: a guide for good practice. Promotion and prevention section, Mental health and special programs branch, Department of Health and Aged Care. Canberra. Weir, W., & Penrose-Wall, J. (1999). Bringing to life the National Mental Health service standards for General Practitioners and Divisions. Iseru (Integration support and evaluation research unit. School of Community Medicine, University of New South Wales. Wilson, A. (2001). Developing performance indicators in mental health. McKesson HBOC Asia Pacific Pty.
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APPENDICES
LACIE 128 Gb:Klemm Family:Digital Reality Freelance:Customers L-Z:Noarlunga Health Services:NHS Collaborative Care Report:TEXT:Eval Collab Care - Sept 05.doc

1. Concepts for Self Management of Mental Illness Mental illness was conceptualised as being similar to chronic physical illnesses where relapse is possible such as diabetes and arthritis. Identifying similarities between physical and mental health conditions clarifies appropriate methods for self management of these conditions, and also identifies a framework for organizing support services for general practitioners. Similarity in symptom pattern Chronic conditions have a distinctive pattern of symptoms where three sets of symptoms can be distinguished: Early warning signs that precede a relapse Symptoms of the full illness Residual symptoms that may persevere after optimal treatment has been provided
Risk Situations or Precipitants In both chronic physical and mental illness there are some everyday life situations that exacerbate the illness, and other lifestyle practices that protect good health. Consumers learn to identify risk situations and protective factors, and manage their lifestyle so as to avoid situations that increase risk of relapse unduly. Risk Attitudes Different stakeholders may have differing attitudes towards taking risks, with people who are more willing to take risks being called risk accepters and people who want to minimize risk being called risk averse. Consumers learn to identify their own risk-attitude, and learn to identify the riskattitude of other people such as carers and professionals. An important part of a self-management strategy involves clarifying the risk-attitude that will prevail. Self Management A model of self management for an illness can be based on the pattern of symptoms described above. Consumers and their carers learn to identify each set of symptoms based on personal experience informed by clinic experience. Consumers and carers learn to respond appropriately to each set of symptoms. Consumers who experience early warning signs respond in an agreed manner so as to avoid relapses. If a consumer experiences symptoms of the full illness, then acute treatment is provided. Consumers and their carers are taught to identify residual symptoms and to communicate these to their treating doctor, knowing that it is possible that no further treatment will be available and that the consumer may need to learn to tolerate these symptoms.

Distinguishing Symptoms from Emotions Consumers learn to distinguish symptoms of illness from normal emotions and side-effects of medication. In a self-management approach, consumers are allowed to express emotions that are normal for the situation. Carer Support Carers play an important role in supporting people who are learning to self manage an illness. Carers can assist in identifying early warning signs of relapse, and in discussing these calmly and objectively. Carers can participate in identifying aspects of a lifestyle that impact on the persons illness in either a positive or negative way. Consumers learn to identify lifestyle practices that increase and reduce their personal risk of relapse and to adjust their lifestyle so as to minimize the risk of relapse. Carers are entitled to express their views about issues that are distressing for the carer, and to obtain support for themselves. Roles of Medication As part of the self management program, consumers learn that medications have different roles when treating different forms of an illness. Medication is used to provide short term treatment for an acute illness, so use of medication ceases when symptoms have gone as the patient is cured. On the other hand, medication is used in an ongoing preventive role for chronic illnesses to avoid a relapse. Consumers need opportunities to learn whether their own illness is acute or ongoing, and to learn which use of medication is appropriate in their case. Non-medical Interventions Consumers learn to deal with precipitators of relapse using non-medical interventions.
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2. Agreed Strengths of Partners The following strengths of partners were identified, informed by (Hickie et al., 2001; Meadows, 2000; I seru, 1997). i Consumer Consumers are able to make decisions about their own care. Some consumers with mental illness need support during a difficult period of illness as indicated by an order of the Guardianship Board. Consumers select between recommended interventions, making informed choice decisions. Professionals empower consumers by providing information when decisions are required, and support decisions once these are made while providing monitoring. ii General Practitioners Skills of General Practitioners for both newly diagnosed consumers and consumers with a diagnosed mental illness include: a. For newly diagnosed consumers A general practitioner is able to: b. Detect and make initial diagnosis of most mental health conditions Explain the likely cause of a presenting disorder Commence initial treatment Screen and make appropriate referrals to mental health services Manage ongoing care within her/his own capacity and support system Complete a risk assessment Take a mental health history
For consumers with a diagnosed mental illness A general practitioner is able to: Be the first point of contact for a consumer and carer Assess mental state and take actions as required Monitor physical health issues, especially issues that may precipitate an episode of mental illness Provide routine appointments for a consumer at a frequency that is agreed to ensure quality care Promote consumer competence Prescribe ongoing medication Be aware of psycho-social changes that are likely to affect mental state, and encourage consumers to discuss occurrence of these stressors Recognise indicators of relapse and provide early intervention for risk of relapse, according to a care plan Monitor compliance with medication as indicated in a collaborative care plan Refer to community services as proposed in a care plan III

iii Recognise indicators that a mental illness is reducing a consumers ability to make informed consent decisions, and assess capacity to give informed consent Refer to mental health services appropriately Prepare a collaborative Care Plan covering the above Arrange a case conference
Key Worker Skills of a multi-disciplinary key worker include: Assessment of mental state, including giving a second opinion for a general practitioner Take a mental health history Identify suitable forms of intervention Provide specialised education about symptoms of mental illness and treatments Assess a consumers current ability to make normal informed decisions about treatment Provide assertive followup including home visits Investigate any role of psycho-social factors in relapse, and assist self management of these issues Identify lifestyle issues that may impact on mental illness, that the consumer is responsible for Identify mental health crises that require intervention by a specialised mental health service Educate carers about mental health issues Collaborate with General Practitioners in developing care plans Contribute to a case conference Educate consumers about community services and link to services Liaise with other agencies about an individual consumer Conduct a risk assessment Negotiate inpatient support if required Recommend psychiatric assessment as required Access a coordinated multi-disciplinary assessment as required Advocate for a consumer
iv Psychiatrist / Registrar In addition to the skills of a key worker, a psychiatrist is able to provide the following: Review diagnoses made by a primary mental health professional Investigate role of biological factors in a relapse Recommend medications Identify the nature of predisposing, precipitating and perpetuating factors of illness
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v Pharmacy Pharmacists are able to: vi Dispense medication according to prescriptions Educate consumers about medications Provide home medication reviews if referred by the consumers general practitioner
Disability Services Non-government disability support services are able to: Provide regular non-specialist contact as required Promote socialisation and integration into community services Accompany consumer to appointments as required Teach daily living skills Support families and carers Provide peer support Provide pre-vocational activities
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Consumer Peer Worker A consumer peer worker is able to: Accompany a consumer to appointments Communicate personal recovery experiences

3. Multi-disciplinary Joint Care Plan Format Date:.................................................. Patient Name: ..................................................D.O.B UR No ............................................... Relevant History / Diagnosis ........................................................................ ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... Current medication(s): Medication Dosage Frequency
Health Care Providers: Name Discipline
Phone
Fax
Date copy sent
Patient consent obtained and documented? I agree to this Care Plan and have received my copy:
Yes / No
..................................................................................................................... Patient Signature Signature of general practitioner responsible for Care Plan:........................ General practitioners Name and Address:................................................... ..................................................................................................................... Care Plan Review Date:.............................................
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COLLABORATIVE CARE IN MENTAL HEALTH

Multi-disciplinary Joint Care Plan Format (Cont..) Problems 1. Goals Management Steps Person Responsible
2.
3.
4.
5.
Early Warning Signs 1
I agree to the above Care Plan .................................................................... Patients Signature Date:.................................................. Review Date / / VII

4. Protocol For Preparing Joint Care Plans A Care Plan is suitable when care is already organized, and the purpose of the meeting is to record what is happening and to clarify points. Care plans are suitable when care of both physical health and mental health issues need to be coordinated. A Case Conference is more suitable when there are significant problems to be solved by discussion between parties. To prepare a Care Plan, three professionals or care providers who are actively involved with the consumer must participate, together with the consumer. A meeting may proceed with only two professionals present, with the third professional later signing or otherwise contributing to the prepared plan. Roles of Key Workers Key workers will be proactive in organizing care plans with the consumers general practitioner. The key worker will be prepared to identify issues to be included in a care plan, and to propose management steps and goals. Key workers will be familiar with use of EPC item 720 for care plans, and will be able to inform General Practitioners and receptionists of usual practice. Shared Care staff will support preparation of Care Plans by presenting care plans to the next clinical review meeting, and by asking a suitable third professional who knows the consumer to comment and to return the plan to the general practitioner. Steps In Preparing A Care Plan There is a sequence of steps when preparing a joint care plan. Key worker discusses the proposal for a case discussion to produce a joint care plan with the consumer and carer. Key worker obtains verbal consent to proceed. Key worker obtains verbal consent from the consumer for an exchange of clinical information with the general practitioner. The key worker initiates a telephone communication with the consumers general practitioner outlining what is proposed. Key worker seeks agreement of the general practitioner to proceed. The key worker arranges an appointment with the general practitioner and consumer at the general practitioners office, booking double time. An appointment is sought at a time that is not too busy for the individual general practitioner practice, such as immediately after lunch. Key worker informs a third member of mental health staff, such as the doctor, about the proposed meeting and asks that person to be available as the third professional for the care plan. The third professional may not be present at the meeting but is available to participate either by phone or by viewing the draft plan after the meeting.
VIII

The keyworker brings relevant paperwork to the meeting, including ideas for a Care Plan. The general practitioner chairs the meeting and completes the care plan. The key worker, consumer and general practitioner make brief statements about current clinical issues that need to be addressed in a care plan. Agreed issues are recorded by the general practitioner. The general practitioner clarifies and records goals, management steps, and the person responsible for each matter, as agreed by participants. The consumer and general practitioner sign the care plan. The general practitioner arranges for two extra copies of the care plan to be made for the consumer and keyworker. The general practitioner arranges for the appropriate EPC item to be claimed (720 for a care plan). Care plans are stated in general terms. Changes to details in care plans can occur without calling a further meeting. Care plans are intended to promote constructive communication, and not to limit the discretion of professionals in the treating team.
September 2003
IX

5. Joint Care Plans for Staff Training Date: 12 June 2003 Patient Name: Henry .............. D.O.B 30 June 1964 UR No ............................................... Relevant History / Diagnosis Henry is a 40 year old single man who lives with his supportive parents. Diagnoses - schizoaffective disorder since age 24 years, Diabetes, High cholesterol levels. Socially isolated and attends community activities when accompanied by a CSI worker. Has difficulty managing finances and has an admin order.
Current medication(s): Medication Olanzapine Dosage 20 mg Frequency nocte
Health Care Providers: Name Discipline Steven Ann Harvey Neil Rex Psychiatrist Key worker General practitioner CSI Public Trust
Phone 8384 9599
Fax
Date copy sent
Patient consent obtained and documented?
Yes / No
I agree to this Care Plan and have received my copy: ............................................................................................................. Patient Signature Signature of General practitioner responsible for Care Plan: ............... General Practitioner Name and Address:............................................. ............................................................................................................. Care Plan Review Date:.....................................

Joint Care Plan Format Problems Schizoaffective disorder Goals Main stability Management Steps Person Responsible Henry and his parents are aware Henry and parents of EWS and steps to take GP
1.
2.
Diabetes
Monitor. Keep BSL < 5.5.
3.
Cholesterol
Monitor. Keep chol < 5.0, TG < 2.0. Support participation in community activities. Live within DSP
Monitor 3 monthly Follow diet, exercise. See dietician 4 monthly. Continue CSI input. General practitioner to renew CSI. Liaise with Public Trust, review need for Admin Order
GP
4.
Social isolation
GP and CSI worker
5.
Finances
Henry and Public Trustee
Early Warning Signs 1 Feeling persecuted
Marked withdrawal, difficulty sleeping
3 Excessive spending
I agree to the above Care Plan .................................................................... Patients Signature Date:.................................................. Review Date / /
XI

Joint Care Plan Format (Cont..) Date: 12 June 2003 Patient Name: Susan ............ D.O.B 2 February 1970 UR No ............................................... Relevant History / Diagnosis Susan is a 34 year old single mother of three young children aged 3, 5 and 6 years. Diagnosis of depression. Without support during school holidays Susan becomes very stressed and is at risk of requiring hospitalisation due to depression. Susans parents are supportive but are unable to provide additional help during school holidays. Current medication(s): Medication Effexor
Dosage 300 mg
Frequency Daily
Health Care Providers: Name Discipline Dr Harris Martin Lucy Rose General practitioner Key worker Respite services Mother
Phone
Fax
Date copy sent
Yes / No
..................................................................................................................... Patient Signature Signature of General Practitioner responsible for Care Plan:....................... General Practitioner Name and Address:..................................................... ..................................................................................................................... Care Plan Review Date: .............................................
XII

Joint Care Plan Format (Cont..) Problems 1. Depression 2. Respite 3. Liaison with mother Goals Avoid severe relapses Balance use of respite and self management Maintain good relations with mother Management Steps Person Responsible Continue with medication for 6 Susan and GP months Improve child management skills Use respite services during long Lucy and Martin school holidays Periodic communication about progress and difficulties Susan and Rose
4.
5.
Early Warning Signs 1. Criticises children and mother unreasonably
2. Withdraws from children into her bedroom
I agree to the above Care Plan .................................................................... Patients Signature Date:.................................................. Review Date / /
XIII

Joint Care Plan Format (Cont..) Date: 28 June 2003 Patient Name: Alex ......... D.O.B 16 December 1974 UR No................................................ Relevant History / Diagnosis Alex is a 30 year old single man who lives in his own private rental accommodation. Current diagnoses of schizophrenia and panic attacks. Has had diagnosis of schizophrenia since aged 19 years. Panic attacks arise when Alex is dealing with daily living issues that he usually manages.
Current medication(s): Medication Respiridone Citalopram
Dosage 2 mg 20 mg
Frequency Bd Daily
Health Care Providers: Name Discipline Dr Smith Martin Joseph Carol Dr Vogel General Practitioner Key worker Father Sister Psychiatrist
Phone
Fax
Date copy sent
Yes / No
..................................................................................................................... Patient Signature Signature of General Practitioner responsible for Care Plan: ....................... General Practitioner Name and Address: ..................................................... ..................................................................................................................... Care Plan Review Date: .............................................
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Joint Care Plan Format (Cont..) Problems 1. Schizophrenia Goals Maintain stability Management Steps Continue with medication. Review prescriptions every 6 months Controlled breathing, withdraw from stressful situation, discuss difficulty with Discuss concerns with sister rather than father who himself becomes distressed if he cannot solve problems. Person Responsible Martin, GP, Alex, Psychiatrist
2. Panic attacks
Use methods of self management for simple anxiety Maintain good relationship
Alex, Martin
3. Concern of father
Alex, Carol
4.
5.
Early Warning Signs 1. Feelings of paranoia
2. Volatile towards father and avoidance. Auditory hallucinations, worsening anxiety.
3.
Deterioration in sleep and self care
I agree to the above Care Plan..................................................................... Patients Signature Date:.................................................. Review Date / /
XV

6. Audit for Written Communication with General Practitioner Number of client files reviewed Time period of review: from / / to / / . Written communication Number of files including a current joint care plan ... Number of files containing a letter to the GP within last 12 months ... Number of files with a record of telephone communication Consumer involvement Number of files with clients signature on the joint care plan . Number of files where the joint care plan lists individual early warning signs of a relapse ..
Reviewers name and signature
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7. Summary of relevant Medicare EPC Funding Items Levels of Consultation Medicare allows for four levels of consultation in the surgery. Level A allows for the doctor to take a short history and to conduct limited examinations. This is claimed as Item 3 and returns $14.10. Level B allows for the doctor to take a selective history, and to implement a management plan that addresses one or more problems. This takes up to 20 minutes, and is claimed as Item 23 returning $30.85. Level C allows for an examination of multiple systems and the arrangement of investigations. The examination will take between 20 and 40 minutes, and is claimed using Item 36 returning $58.85. Level D allows for a comprehensive examination of multiple problems that lasts at least 40 minutes. This is claimed suing Item 44 and returns $86.00. Enhanced Primary Care The Enhanced Primary Care package is an initiative of the Commonwealth government that provides remuneration to GPs to work collaboratively with other health providers around the health of people with chronic and complex conditions. There are 3 components 1. 2. Annual Health Assessments Item Number 700 Care Plan Item Numbers (720 730)
Item 720 provides remuneration for GPs to prepare a care plan for patients with chronic health conditions that requires multi-disciplinary care for six months. At least three care providers from different disciplines need to be named on the EPC Care Plans and evidence of collaboration included in the GP notes. The Care Plan is developed by the GP with the patients and a copy of the Care Plan needs to be provided to the patient and all participants. There is also a discharge Care Plan Item 722 and Item 724 for review of care plans. There are also Items 726, 728 and 730 for GPs participating in a Community Care Plan, Discharge Plan and review of care plans respectively. 3. Case Conferencing Item Numbers (730 773)
There are Items that provide remuneration for GPs to be involved in multidisciplinary case discussions and payments are according to three time tiers 15 30 minutes, 30 45 minutes and over 45 minutes.
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There are item numbers covering:

Residential Aged Care Facilities. For organising Items (734 738) for participating Items (775 779); In the Community for organising items (740 744) for participating Items (759 765) and On discharge for organising Items (746 757) for participating Items (768 773).
Health Assessments, Care Plans and Case Conferences can be carried out once annually unless there is a significant change in health status of a patient. Care plans can be reviewed every three months. If a patient has an EPC Care plan they are eligible for up to: 1. Five services from private Allied health providers who are registered with the HIC. 2. Three dental services if oral health is identified, the first service being a dental assessment. On referral from a General Practitioner.
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8. Revised questionnaires used for evaluation
NA Not applicable 0 Very poor 1 Poor 2 Acceptable 3 Good 4 Very good 5 Exceptional
EVALUATING COLLABORATIVE CARE CONSUMER FEEDBACK

This questionnaire has been prepared to gather feedback from consumers about the collaborative care programme provided by the Adaire Clinic. Feedback will be obtained by interviewing individual consumers using the questionnaire. De-identified information will be used to improve the service as required. Please rate answers using the above scale: 1. Rate how easily you believe you can access Staff of the Adaire Clinic when you require assistance: NA 0 1 2 3 4 5
Comment . 2. Rate your confidence in the ability of Staff of the Adaire Clinic to deal with issues you raise: NA 0 1 2 3 4 5
Comment . 3. Please rate the level of respect shown to you in communication by Staff of the Adaire Clinic: NA 0 1 2 3 4 5
Comment . 4. Rate how easily you believe you can access your GP when you require assistance: NA 0 1 2 3 4 5
Comment . 5. Rate your confidence in the ability of your GP to deal with issues you raise: NA 0 1 2 3 4 5
Comment . 6. Please rate the level of respect shown to you in communication by your GP: NA 0 1 2 3 4 5
Comment .
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NA Not applicable 0 Very poor 1 Poor 2 Acceptable 7. 3 Good 4 Very good 5 Exceptional
Is finance a factor in your decision to see your GP? Yes Partly No
Comment . 8. Rate how clearly the care plan states what each professional will provide for you: NA 0 1 2 3 4 5
Comment . 9. Please rate how well you feel you are included in making decisions that affect your care: NA 0 1 2 3 4 5
Comment ..... 10. Rate whether you believe that sharing of information with your carer is satisfactory: NA 0 1 2 3 4 5
Comment . 11. Please rate your overall satisfaction with the total care provided to you: NA 0 1 2 3 4 5
Comment . 12. Do you have any other comments?
Comment . .. .. .. .. .. Thank you for participating in this survey.
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EVALUATING COLLABORATIVE CARE CARER FEEDBACK

This questionnaire has been prepared to gather feedback from carers about the collaborative care programme provided by Adaire Clinic. Feedback will be obtained by interviewing individual carers using the questionnaire. De-identified information will be used to improve the service as required. Please rate answers using the above scale: 1. Rate how easily you believe the person you care for can access Staff of the Adaire Clinic when assistance is required: NA 0 1 2 3 4 5
Comment 2. Rate your confidence in the ability of Staff of Adaire to deal with issues raised by the person you care for: NA 0 1 2 3 4 5
Comment 3. Please rate the level of respect shown to you by Staff of Adaire when discussing the person you care for: NA 0 1 2 3 4 5
Comment 4. Rate how easily you believe the person you care for can access the GP when assistance is required: NA 0 1 2 3 4 5
Comment 5. Rate your confidence in the ability of your GP to deal with issues raised by the person you care for: NA 0 1 2 3 4 5
Comment 6. Please rate the level of respect shown to you by the GP when discussing the person you care for: NA 0 1 2 3 4 5
Comment
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Is finance a factor in decisions by the person you care for to see a GP? Yes Partly No
Comment 8. Rate how well the care plan states clearly what each professional will provide for the person you care for: NA 0 1 2 3 4 5
Comment 9. Please rate your satisfaction with your opportunities to participate in decisions when there is a proposal to change the care plan for the person you care for: NA 0 1 2 3 4 5
Comment 10. Rate your satisfaction with the sharing of information with you as Carer: NA 0 1 2 3 4 5
Comment 11. Please rate your overall satisfaction with the collaborative care arrangement: NA 0 1 2 3 4 5
Comment 12. Do you have any other comments?
Comment . . . . Thank you for participating in this survey.
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EVALUATING COLLABORATIVE CARE GP FEEDBACK

This questionnaire has been prepared to gather feedback from GPs about the collaborative care programme provided by Adaire Clinic. The GP is asked to answer questions about a joint client of the GP and Adaire Clinic, who will be named by the interviewer. De-identified information will be used to improve the service as required. Please rate answers using the above scale. 1. Rate your ability and confidence to deal with issues raised by this client: NA 0 1 2 3 4 5
Comment ..... 2. Rate your capacity to find time the meet the needs of this client: NA 0 1 2 3 4 5
Comment ..... 3. Rate how easily you believe you can access Staff of Adaire when you require assistance with the client: NA 0 1 2 3 4 5
Comment ..... 4. Please rate the level of respect shown to you in communication by the Staff of Adaire: NA 0 1 2 3 4 5
Comment ..... 5. Rate how well the Collaborative Care arrangement uses the expertise and skills of both: NA NA 0 0 1 1 2 2 3 3 4 4 5 5
Yourself Adaire Staff
Comment ..... 6. Rate your satisfaction with the Care Plan document to support collaborative work: NA 0 1 2 3 4 5
Comment .....
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Rate your opportunity to participate in decisions when interventions are changed: NA 0 1 2 3 4 5
Comment ..... 8. Is finance a factor in your participation with this client? Yes partly No
Comment ..... 9. Please rate your overall satisfaction with the collaborative care arrangement for this client: NA 0 1 2 3 4 5
Comment ..... 10. Do you have any other comments?
Comment . .. .. .. .. .. .. Thank you for participating in this survey.
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EVALUATING COLLABORATIVE CARE KEY WORKER FEEDBACK

This questionnaire has been prepared to gather feedback from Key Workers about the Collaborative Care Programme provided by the Adaire Clinic. The Key Worker is asked to answer questions about a joint client of the Adaire Clinic and a GP who will be named by the interviewer. De-identified information will be used to improve the service as required. Please rate answers using the above scale. 1. Rate your capacity to find time the meet the needs of this client: NA 0 1 2 3 4 5
Comment ..... 2. Rate your ability and confidence to deal with issues raised by this client: NA 0 1 2 3 4 5
Comment ..... 3. What has been the most effective way of contacting the GP and why was this effective?
Comment ..... .. 4. Have you experienced any difficulties contacting GPs? Yes No
Comment ..... 5. Have you contacted the Carer about the client in the last 6 months? Yes No
Comment ..... 6. Rate how well the Collaborative Care arrangement uses the expertise and skills of both: NA NA 0 0 1 1 2 2 3 3 4 4 5 5
Yourself GP
Comment .....
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Rate your satisfaction with the structures of the Collaborative Care Programme to support and inform collaborative work: NA 0 1 2 3 4 5
Comment ..... 8. Rate your satisfaction with the Care Plan document to support collaborative work: NA 0 1 2 3 4 5
Comment ..... 9. Is finance raised as a factor in the Collaborative care arrangement with this client? Yes partly No
Comment ..... 10. How could a more effective service be provided by the Collaborative Care Programme?
Comment ..... .. .. 11. Please rate your overall satisfaction with the Collaborative Care arrangement for clients: NA 0 1 2 3 4 5
Comment ..... 12. Do you have any other comments?
Comment . .. .. .. Thank you for participating in this survey.
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EVALUATING COLLABORATIVE CARE NON-GOVERNMENT AGENCY FEEDBACK

This questionnaire has been prepared to gather feedback from Non Government Agencies about the Collaborative Care Programme provided by the Adaire Clinic. Feedback will be obtained via an interview. The Agency is asked to consider questions about service provision by the Adaire Clinic. De-identified information will be used to improve the service as required. Please rate answers using the above scale. 1. Could you rate how well you perceive the Collaborative Care Programme to be operating? NA 0 1 2 3 4 5
Comment ..... 2. Do you / your workers see any issues with the Collaborative Care Programme? NA 0 1 2 3 4 5
Comment ..... 3. Could you rate the support provided by the Collaborative Care Programme?
Comment ..... .. 4. Have you / your workers found any confidentiality issues regarding the Collaborative Care Project? NA 0 1 2 3 4 5
Comment ..... 5. Could you rate the coordination provided by the Adaire Clinic Keyworkers? NA 0 1 2 3 4 5
Comment ..... 6. Are there any areas where you seek training arising from care of mental health clients?
Comment ..... .. ..
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NA Not applicable 0 Very poor 1 Poor 2 Acceptable 7. Do you have any other comments? 3 Good 4 Very good 5 Exceptional
Comment ..... .. .. .. .. .. .. Thank you for participating in this survey.
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Collaborative Care in Mental Health

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Collaborative Care in Mental Health

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Collaborative Care in Mental Health in Noarlunga

Adaire Clinic Division of Mental Health Noarlunga Health Services

Noarlunga Consumer Advisory Group and Southern Division of General Practice

Project Officer Don Tustin

Funded by Innovation Initiatives Program Department of Health South Australia