Post a (200 Word APA Format) explanation of how you think you would be affected personally by the implementation of the mental heath integration model. Be specific, using the model and your situation to illustrate your points.

FarWestAreaHealthServicementalhealthintegrationprojectmodelforr.pdf

Home >Social Science homework help >Post a (200 Word APA Format) explanation of how you think you would be affected personally by the implementation of the mental heath integration model. Be specific, using the model and your situation to illustrate your points.

Aust. J. Rural Health (2006) 14, 105–110

Blackwell Publishing AsiaMelbourne, AustraliaAJRAustralian Journal of Rural Health1038-52822006 National Rural Health Alliance Inc.? 2006143105110Original ArticleFAR WEST MENTAL HEALTH INTEGRATION PROJECTD. A. PERKINS ET AL.

Correspondence: Dr David Perkins, CEPHRIS, PO Box 2087, Wollongong 2500, New South Wales, Australia. Email: [email protected]

Accepted for publication 15 February 2006.

Original Article

Far West Area Health Service Mental Health Integration Project: Model for rural Australia? David A. Perkins,1 Russell Roberts,2 Tuana Sanders2 and Alan Rosen2,3,4,5,6

1Centre for Equity and Primary Health Research in the Illawarra and Shoalhaven, University of New South Wales, Sydney, 2Greater Western Area Health Service, Orange and Broken Hill, 3Royal North Shore Hospital and 4Community Mental Health Services, 5School of Public Health, University of Wollongong, Wollongong, and 6Department of Psychological Medicine, University of Sydney, Sydney, New South Wales, Australia

Abstract Objective: To see if a new model of service delivery ensures that individuals with a mental illness in rural and remote settings could be assessed, treated and cared for in a more appropriate way. Design: Community mental health teams (CMHTs), general practitioners (GP) and other agencies were pro- vided with clinical and broader support services by con- sultant psychiatrists from public and private sectors. The occasions of service were logged, audited and rele- vant provider groups were interviewed. Ethics approval was provided by Human Research Ethics Community of University of New South Wales. Setting: Far West Area Health Service (FWAHS), remote New South Wales. Participants: An enhanced service was provided for res- idents, specialist mental health and other healthcare providers. Results: • Regular access to psychiatrists for primary and sec-

ondary care was achieved in remote communities in FWAHS.

• 3908 new patients were seen by CMHTs between July 2002 and December 2003 and 380 by visiting psychi- atrists between January 2002 and July 2003.

• Secondary consultation, mentoring and education opportunities were made available by tele-conference and face-to-face for CMHTs and others in FWAHS.

• GPs and CMHTs in remote settings were satisfied with improved access to psychiatrist care.

Conclusions: This model appears to be sustainable with reasonable levels of funding in FWAHS and may be applicable to other remote contexts.

KEY WORDS: access, integrated service, mental health, remote, visiting.

Introduction The 1993 National Health Strategy proposed significant reform in provision of mental health services. It pro- posed multidisciplinary service delivery, a single point of entry for patients, an information system to support continuity and integration of services, and major reforms in financing. It found, few financing incentives for the integration of public and private specialised men- tal health services to ensure wider access and continuity of care for people with chronic mental illness.1

The Second National Mental Health Plan 1998 found widespread failings in integration.2 As part of the imple- mentation of the plan the Commonwealth Government sought expressions of interest from Area Mental Health Services to demonstrate: • Evidence of broad interest from public and private

sectors in conducting a demonstration project • A description of current integration mechanisms • An outline of a broad integration strategy to be

followed • An agreement between stakeholders to collect rou-

tine patient outcomes. Three projects were funded with the following aim:

To establish and document approaches to integrating private psychiatrist and public mental health services. The purpose is to create a more flexible integrated framework within which mental health can be delivered.3,4

These projects were collectively called Mental Health Integration Projects (MHIP). The Far West Area Health Service (FWAHS) was selected to receive planning and then project funds. The live phase commenced in 2000 and the evaluation was published in December 2003.5

This paper reports research conducted in the evaluation process.

106 D. A. PERKINS ET AL.

The Third Mental Health Plan 2003 includes the fol- lowing key principle:6all people in need of mental health care should have access to timely and effective services, irrespective of where they live.

Context The FWAHS occupies one-third of the landmass, but with about 50 000 people has less than 1% of the NSW population (Fig. 1). The Australian Bureau of Statistics has classified the entire area as remote. Thir- teen per cent of the population are Aboriginal, com- pared with 1.7% in the State. The area was rated as having the highest level of socioeconomic disadvantage in Australia.7

Twelve per cent of the FWAHS population have needs that are usually treated by public mental health services, that is, affective disorders, personality disorders, psy- choses or cognitive impairment. About 20% have needs usually treated by private mental health practitioners that is, affective disorders, anxiety disorders and substance abuse. Only eight Area Health Services in

Australia had a higher prevalence of these disorders in 2002.7

In 1997 the Australian Medical Workforce Advisory Committee reported a serious maldistribution of psychi- atrists with one psychiatrist per 6610 people in capital cities, one per 20 593 in large rural centres and one per 41 283 in other rural and remote centres.8

In consequence, Far West residents receive a small proportion of Medicare monies spent on private psychi- atrist services because there are no resident private psy- chiatrists in the area. In the early 1990s the FWAHS mental health service was regarded as a model service being awarded silver and gold ANZ Mental Health Service Achievement awards. However, the loss of key staff in the 1990s had a damaging effect on the quality of the service.9

There is one resident public psychiatrist based in Broken Hill serving 50 000 people. There is high staff

What this study adds: • This study was undertaken to see if a better

mental health services model could improve access to psychiatrists in remote communities and support resident health care providers and GPs.

• This study shows that it is possible to provide a good-quality mental health service in remote communities using a primary health care model where access is improved, local staff are supported and most patients are cared for in their communities.

FIGURE 1: Far West Area Health Service.

Pooncarie

Louth

Enngonia

Wanaaring

Tilpa

Towns in the Far West Area Health Service

White Cliffs Bourke

Brewarrina

Goodooga

Lightning Ridge

Walgett

Collarenebri

Dareton

Euston Balranald

Coomealla

Ivanhoe

Wentworth

Wilcannia

Menindee

Broken Hill

Tibooburra

What is already known on this subject: • Psychiatrists have been visiting remote

communities on an ad hoc basis for many years, often flying in and out on the same day. Their work has consisted almost entirely of patient assessment and the services provided have not been comprehensive or locally based.

FAR WEST MENTAL HEALTH INTEGRATION PROJECT 107

turnover among public mental health staff who have fewer years of experience compared with their urban counterparts. Two metropolitan psychiatrists have vis- ited Broken Hill for many years fulfilling a clinical role.10 A short-term project provided psychiatrists on a day visit basis to Lightning Ridge and one psychiatrist occasionally visited Dareton.

Objectives The project objectives were: • To provide access to comprehensive mental health

services • To encourage multi-professional collaboration and

coordination • To increase the focus on prevention and promotion • To develop a coherent funding mechanism • To enable consumer participation • To provide education and support for mental health

workers and primary health professionals.

The Far West Mental Health Integration Project (FW-MHIP) model The FWAHS Strategic Plan adopted a population health approach to planning and a primary health care model of service delivery because the population is scattered over a large area, resources limited and health problems increasingly lifestyle-related.11 This model ensures that mental health services are an integral part of primary health care and population health (Fig. 2).

Psychiatrists visit on a regular basis from metropol- itan centres as do allied mental health specialists from the Broken Hill headquarters. Their visits include patient consultations and secondary activities such as caseload review, mentorship and education of local mental health and primary care staff. Resident staff continue planned care between visits and are able to consult by phone if necessary. They receive regular supervision and support from psychiatrists

FIGURE 2: The Far West Mental Health Integration Project model. CMHT, Community mental health team; FWAHS, Far West Area Health Service.

Core philosophy Elements of model

era secivres htlaeh latnem yramirp – ygetarts erac yramirP provided by local generalist staff supported by specialists from hubs and visiting psychiatrists from metropolitan centres

Hub structure – CMHTs support general health staff and provide specialist services to patients

Funding mechanism – The Area Health Service was given the funds it would receive if it had the national average number of private psychiatrists working across the area and received an equitable share of State mental health funds.

The local resident mental health team, general practitioners (GPs) and other providers are supported by specialist mental health and counselling staff and visiting psychiatrists

Management process – Local mental health services are provided by a CMHT working with GPs, generalist health staff and others managed by a team leader who reports to the Director of Mental Health and Counselling.

Visiting Patterns – An increase in the number of visiting psychiatrists was achieved. Psychiatrists were strongly encouraged to stay for one or more nights in the communities they visited.

VMO roles – Specialist psychiatrists were appointed as Visiting Medical Officers and encouraged to undertake a mix of primary and secondary activities to meet the needs of the teams and the communities serviced and to contribute to the wider service.

Governance mechanism – The project was treated as core business, covered the whole mental health and counselling service and was subject to the normal governance mechanisms of the FWAHS

108 D. A. PERKINS ET AL.

enhancing staff development and contributing to job satisfaction.

This model was implemented as the core service model, with no private referrals to the visiting psychia- trists who are Visiting Medical Officers. Referrals are made to the mental health team who refer to visiting psychiatrists where appropriate. The team leader plans the visits of psychiatrists and allied specialists to meet priority needs and is responsible to the Area Director of Mental Health and Counselling.

Results

Access to psychiatrists

The implementation of FW-MHIP sectors provided regular access to a psychiatrist for the first time for patients from outside Broken Hill. Table 1 shows the number of new patients seen by psychiatrists by sector from January 2002 to June 2003. The figures in brack- ets show new referrals as a percentage of all referrals seen. Low first quarter figures reflect the start-up diffi- culties and the introduction of psychiatrist activity reporting processes. New referrals represent about half of the patients seen. Team leaders reported that it is usually possible to ensure that those requiring a spe- cialist consultation see the psychiatrist on his/her next visit.

Access to community mental health teams (CMHTs)

Community mental health teams saw a large number of new clients with a wide range of mental health and other disorders (Table 2). Many of these individuals were seen by the visiting psychiatrist and are also recorded in Table 1.

Table 3 provides a breakdown of individuals by diagnosis seen between July 2000 and December 2002.

Support activities

Support activities were undertaken by a visiting psychi- atrist with no patient present and the objective was to assist local providers including: CMHT members, gen- eral practitioners (GPs), hospital staff, Aboriginal med- ical services staff and other agencies. These activities accounted for 10–20% of specialist activity throughout the project and included case review, mentorship, sec- ondary consultation and education for mental health, acute and primary care staff.

Collaboration

Collaboration with GPs improved but was not a spec- tacular success for a number of reasons. GPs were in short supply and reported being overworked with little time for non-core activities. GP turnover was significant and relationships with visiting psychiatrists take some time to build. Many GPs were happy to refer to the CMHT, and through the team to a psychiatrist, and to await a letter from the specialist in a traditional manner. However, GPs reported high quality instances of second- ary consultation ranging from regular meetings with the visiting psychiatrist to discuss issues such as treating patients with personality disorders to one-off but valued secondary consultations.

Discussion Increased resources and a new flexibility in their use enabled improved access to mental health services in a remote context. These improvements are demonstrated by the number of patients seen by psychiatrists and CMHTs and reductions in or elimination of waiting times.

Local access was critically important for some Aboriginal and non-Aboriginal patients who typically refused to travel for specialist care. As a secondary consideration medical evacuations are an expensive option for all concerned.

TABLE 1: New referrals seen by visiting psychiatrists by hub

Sector January–March 2002

April–June 2002

July–September 2002

October–December 2002

January–March 2003

April–June 2003

Total 2002/03

Broken Hill 3 (60) 36 (61) 31 (47) 32 (52) 29 (67) 19 (40) 150 Dareton 6 (35) 5 (20) 6 (28) 6 (25) 6 (26) 10 (41) 39 Lightning Ridge 17 (44) 17 (53) 10 (28) 9 (34) 14 (32) 21 (47) 88 Bourke 11 (55) 18 (56) 13 (52) 23 (58) 17 (60) 21 (51) 103 Total 37 76 60 70 66 71 380

Brackets show new referrals as percentage of all patients seen by visiting psychiatrist. Based on manual reporting by psychiatrists which explains why data are only available for six quarters.

FAR WEST MENTAL HEALTH INTEGRATION PROJECT 109

The key to the model is the balance of primary and secondary activities. Specialist visits worked best where they were carefully planned in advance by the resident team leader and were part of a strategy to address key community needs and to build the skills and experience of resident staff.

The best evidence of the value of secondary activity was the strong relationship between visiting psychia- trists and CMHTs. This was built through mentorship, caseload review, educational activities and joint consul- tation. This broad ranging role was possible because of flexibilities in the FW-MHIP model. Visiting psychia- trists acted as general psychiatrists not specialists in a particular condition but were able to contribute their specialist expertise through monthly tele-education ses- sions broadcast to the four hubs and attended by CMHT members, acute and primary health services staff.

Community mental health team members reported that opportunities for mentorship, education and sup- port are important factors in recruitment and particu- larly retention of staff in the early years of their career particularly in the light of the professional and social isolation experienced in remote towns.

The sustainability of this model depends on each element working within a broadly agreed set of goals and values. The practice of visiting rural or remote locations is not uncommon. The key is what happens before, during and after the visit and the way in which a series of visits contributes to the local service. The motivation of visiting psychiatrists needs to be monitored recognising factors that improve their expe- rience and addressing administrative and organisa- tional problems that might detract from their experience.

This model could not have developed and is not sus- tainable under normal Medical Benefits Schedule fee- for-service arrangements. Its success depends on both the quantity of funds and flexibility in their use.

Conclusion This model focuses on the needs of local populations and providers; hence the role of local management and the team leaders is particularly important. FW-MHIP was designed to be scaled and adjusted to fit the needs of different populations such as Broken Hill and Bourke. In each sector the CMHT leader is the local manager and plays a similar role despite differences in team size and composition.

Although outcome data are scarce, information on activity is critical to assess access improvements, quan- tify support activities and see how the model is working. Project governance was informed by findings from pre- vious programs such as the coordinated care trials.10T

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The project was managed as part of core business and therefore the FW-MHIP model became the service model, not a pilot or project.

It has achieved improvements in access for residents of remote communities at low cost.

It has proved attractive to each of the provider groups and has won support from related health and other services.

Finally, the model requires a significant investment in planning, design and implementation. This would be critical in any attempt to replicate it in other remote or rural contexts.

Acknowledgements The authors would like to acknowledge the contribution of the consumers, staff, management, GPs and visitors to the Far West who have generously found time to answer questions, collect data, complete questionnaires and contribute to the research reported here. The project was funded by the Mental Health Branch of the Austra- lian Government and by New South Wales Health.

References 1 Commonwealth Department of Health and Family Ser-

vices. Help Where Help is Needed: Continuity of Care for People with Chronic Mental Illness. Canberra: National Health Issues Strategy, 1993. Paper no. 5.

2 Australian Health Ministers’ Conference. National Men- tal Health Policy. Canberra: Australian Government Pub- lishing Service, 1992.

3 Eagar K, Owen A, Perkins D et al. Planning Guidelines for the National Demonstration Projects in Integrated

Mental Health Care. Canberra: Commonwealth of Australia, 1999. Discussion Papers 1–6.

4 Perkins DA. Towards integrated mental health services in rural and remote Australia in Leaping the boundary fence: using evidence and collaboration to build healthier rural communities. Proceedings of the 5th National Rural Health Conference, pp. 486–492, 14–17 March 1999, Adelaide, SA, Australia.

5 Perkins DA, Lyle D. Far West Mental Health Integration Project Evaluation Report. Canberra: Australian Govern- ment Department of Health and Ageing, 2003.

6 Australian Health Ministers. National Mental Health Plan, 2003–2008. Canberra: Australian Government, 2003.

7 Burgess P. et al. Mental Health Needs and Expenditure in Australia. Canberra: Mental Health and Special Pro- grams Branch, Commonwealth Department of Health and Ageing, 2002.

8 Australian Medical Workforce Advisory Committee. The Specialist Psychiatry Workforce in Australia. AMWAC Report 1999.7, Sydney.

9 Rosen A, Hemming M. Rural and remote mental health services: what the city can learn from the Bush, keynote address. Proceedings of the Rural Mental Health Confer- ence, 1997, Broken Hill, Australia.

10 Owen C, Tennant C, Jessie D, Jones M, Rutherford V. A model for clinical and educational psychiatric service delivery in remote communities. Australian and New Zealand Journal of Psychiatry 1999; 33: 372–378.

11 Far West Area Health Service. Strategic Plan. Broken Hill: Far West Area Health Service, 1998.

12 Perkins DA, Owen A. Lessons in governance from care net Illawarra. The Australian Co-ordinated Care Trials: Reflections and Lessons. Canberra: Commonwealth Department of Health and Aged Care, 2001; 105–113.

TABLE 3: New referrals seen by CMHTs by diagnosis and hub July 2000–December 2002

Broken Hill Dareton Lightning Ridge Bourke Total

Not yet allocated 209 47 30 405 691 Mood disorder 317 115 51 93 576 Depression and anxiety 60 40 47 19 166 Anxiety disorder 52 54 108 25 239 Psychotic disorder 132 25 43 29 229 Alcohol/drugs 119 22 48 36 225 Other 311 130 116 61 618 Mental health diagnosis not applicable 190 22 9 86 307 Total 1390 455 452 754 3051

CMHT, community mental health team.