SA Health Mental Health Report 29072013 FINAL.docx

Department for Health and Ageing, South Australia Review of the South Australian stepped system of Mental Health care and capacity to respond to emergency demand 29 July 2013

Department for Health and Ageing, South Australia Review of the South Australian stepped system of Mental Health care and capacity to respond to emergency demand

Table of contents 1. Context of this review .................................................................................................... 1 2. Summary findings and recommendations......................................................................... 2 3. Detailed findings and recommendations........................................................................... 5 Appendix A Scope and approach ......................................................................................... 17 Appendix B Stakeholders consulted..................................................................................... 18 Appendix C Comparator MH systems ................................................................................... 19 Appendix D Glossary of terms ............................................................................................. 21 Appendix E Reference documents ....................................................................................... 22

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1.

Context of this review

The Mental Health (MH) system in South Australia (SA) has undergone significant reform, with the foundation set by the National Mental Health Plans from 1993, Social Inclusion Action Plan for Mental Health Reform 2007-2012 (Stepping Up report) and the Review of Community Mental Health Services in 2008. The Government has since committed more than $330 million to reform and rebuild the State’s MH system. Although substantial reform has occurred, the MH system in SA has experienced growing pressure within all Emergency Departments (ED) in respect to acute MH patient demand. Given this context, EY has been engaged by the Department for Health and Ageing, SA (the Department) to undertake a Review of the South Australian stepped system of MH care and capacity to respond to emergency demand. The specific areas of focus for the Review included: • • • •

An assessment of the capacity and processes of the SALHN to effectively manage acute demand and examine waiting times in the Flinders Medical Centre ED An assessment of bed coordination and patient flow practices, and examination of the practices and processes underpinning emergency MH responses across the State An assessment of the balance of acute and non-acute mental health services A desktop review of the basis and assumptions of the Stepping Up report recommendations and how they compare with current evidence based practice

The detailed scope and approach taken by EY in conducting this Review is outlined at Appendix A. Key stakeholders and organisations consulted are summarised in Appendix B.

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2.

Summary findings and recommendations

Summary questions and findings A comparative data analysis undertaken and referred to elsewhere in this report indicates that at a whole of system level South Australia is not underfunded compared to other States. Indeed per capita spending on mental health by SA is above the national average at $167.25 per capita versus the national average of $151.63 per capita. Accordingly, this and other benchmark analysis undertaken as part of the review, indicates that further changes to the mental health system in South Australia should largely be resourced through a process of reallocation rather than new investment. From our perspective, there are eight major questions arising from our Review that address the specific issues impacting on acute and non acute MH patient demand. The following table summarises the key questions and associated answers. More detail, including associated evidence to support these questions is provided in Section 3. Question #

Question description

Key findings

Question 1

Does the EY Review support current Government MH policy as documented in the Stepping Up report and recommendations?

Yes. The Review supports the reforms set out by the Stepping Up report in 2007.

Question 2

Are there problems with the way in which the Stepping Up report has been implemented?

Yes. The implementation of Stepping Up has presented a slower than expected change in culture and clinical practice. It has also presented a clinically risk adverse culture in some community MH services and in some acute services. The impact has been an increase in the likelihood of consumers being referred to acute services and a reduction of the likelihood of earlier discharge to a nonacute setting. We also identified an absence of strategies to support a system which builds the confidence of clinicians in supporting more consumers within a community based setting.

Question 3

Are there sufficient adult acute inpatient beds available in the SA MH system?

There are sufficient adult acute inpatient beds available in the SA MH system. However the answer is not as simple as ‘yes’ or ‘no’ given the challenge in comparing across states, the imbalance between acute and non-acute services and the rate of reform.

Question 4

How can ED function better for MH Consumers?

The comparator analysis of the Alfred Hospital (Victoria) highlighted considerable improvement is possible through a range of initiatives such as training and development, introduction of more nurse practitioners, clear protocols and reduction in the use of seclusion rooms.

Question 5

Should the catchment areas for LHNs and the MH system catchment areas be the same?

The MH system and LHN catchment areas should be the same in order to provide services closest to the consumer’s home and to better coordinate with all providers in future service planning.

Question 6

Is there a need to reallocate staff within the SALHN?

Yes. There is a significantly higher level of medical staff and a slightly higher level of nursing staff in SALHN’s acute services and conversely a lower level in non acute services compared to other LHN’s. In light of the need to improve the risk adverse culture of community MH services and reduce the need for consumers to be referred to ED and inpatient services in SALHN, a reallocation of some FTE for medical staff is warranted. There is a case for changing the nursing staff mix within acute services and this is referred to later in the report.

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Question #

Question description

Key findings

Question 7

Who should operationally manage Mental Health Services including bed triage and allocation of patients to LHNs?

The LHNs should manage the operations of the MH Services. Many of the elements that contribute to the success of this service at the Alfred are achieved because of the autonomy allowed to make local decisions regarding models of care, staffing structures, and seeking own-source revenue. While there is a theoretical benefit in managing beds on a state-wide basis to ensure maximum efficiency and effectiveness in bed use, in practice this outcome is not achieved. Failure to manage locally reduces local accountability and encourages practices to hold consumers in beds for longer than necessary to protect capacity for future patient referrals. At one of our site visits staff openly stated that occurs.

Question 8

What should be the reallocation of resources between LHNs?

A clear need exists to reallocate some resources between LHN’s. Catchment area realignment will require this as a matter of course. However, there is a clear disparity in resources for NALHN versus others, and in particular the SALHN.

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Summary recommendations The following table summarises the 15 key recommendations relating our Review questions and findings. Question #

Recommendations

Question 1

Not applicable. Refer to question 2.

Question 2

• •

• •

Question 3

• •

Question 4

• •

• •

Recommendation 1: Design and deliver a comprehensive change management program to implement the remaining reform focussing on the priority recommendations in this Review Recommendation 2: Develop a new function in ED delivered by MH nurse practitioners to optimise timely admission/discharges through changes to the acute care pathway and medical/nursing delegations. This recommendation along with other measures outlined in recommendations 7, 8 and 9 should also reduce seclusion and restraint rates. Recommendation 3: Design and deliver a training and development program for MH staff in acute, non acute and in support areas such as Ambulance, Police and Correctional Services to improve workforce capability. Workforce capability is considered to be a critical success factor in the Alfred MH Service in Victoria Recommendation 4: Consider how the content from third parties (such as the Victorian Department of Health and in particular the Alfred Health) can be leveraged in designing the training and development programs. Some adaptation may be required however this is likely to be minimal. Recommendation 5: Close no further adult acute inpatient beds in the MH system until a greater acute/non acute balance is achieved and the ‘flexing’ of SALHN MH inpatient beds is stabilised. This should be achieved within 12 months. This should be achieved within 12 months. Recommendation 6: Re-assess the bed capacity once the Review recommendations are underway (including the introduction of further planned and funded Stepping Up initiatives outlined herein) with the intent of further shifts in resources to non acute services and to better balance resources between LHNs. This process should take up to 12 months at which point a migration plan can be finalised with the appropriate Departmental resource support. Recommendation 7: Develop and apply a consistent ED/MH Team set of triage criteria and protocols Recommendation 8: Design and implement a system within ED to alert MH teams of repeat consumers so they can be more actively managed to reduce incidence of ED contact in the future. This system should include the development of procedures to support an escalation of a case review for known clients re-presenting multiple times e.g. 3 times in a month; 6 times in 6 months Recommendation 9: Establish an ED/MH team liaison meeting with a Terms of Reference to monitor the advancement of practice development, practice change and outcome monitoring Recommendation 10: Consider the development of local telephone triage assessment with an underpinning competency framework connected to Community Mental Health Teams (CMHTs)

Question 5

•

Recommendation 11: Align the LHN and MH catchment areas. The Department should run a population and needs resource reallocation model to rebalance resources between LHNs based upon their population coverage and service need

Question 6

•

Recommendation 12: Change the nursing skill mix for acute services at SALHN in order to accommodate nurse practitioners Recommendation 13: Reallocate approximately 3-5 FTE from hospital based medical staff at SALHN, to community MH services within SALHN

•

Question 7

• •

Question 8

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•

Recommendation 14: The LHNs should operate the MH Services. Redefine the role and accountability of the Department and the LHN’s such that LHNs have full operational accountability and responsibility for the MH service delivery Recommendation 15: Review the required change in FTE for the MH Unit of the Department in light of the changes in LHN accountabilities Refer to Recommendation 11


3.

Detailed findings and recommendations

The following section outlines the detailed Review findings, supporting evidence and 15 key recommendations relating to each of the eight questions arising from this Review.

Question 1: Does the EY Review support current Government MH policy as recommended in the Stepping Up report? Findings In 2005, the SA Government asked the former Social Inclusion Board to examine SA’s MH facilities and system as a whole, including the Glenside Campus. In 2007, the Stepping Up report was released. The Stepping Up report set out 41 recommendations across nine areas to build a Stepped model of delivering care with community services at its centre. The Review supports the reforms set out by the Stepping Up report in 2007. Our view is the report findings were based on sound analysis and examination of MH reforms that are well established and supported in Australia and internationally.

Supporting evidence The basis and assumptions for the recommendations compare favourably with current evidenced based practice. When reviewing these recommendations, it is striking how many remain relevant today, despite any reforms in MH systems and practice since that time.

Recommendations Refer to question 2 regarding the implementation of Stepping Up report recommendations.

Question 2: Are there problems with the way the Stepping Up report has been implemented? Findings A comprehensive roll out of a capital infrastructure program has occurred in relation to the Stepping Up report. However, the implementation of Stepping Up has presented a slower than expected change in culture and clinical practice. It has also presented a clinically risk adverse culture in some community and acute MH services. The impact has been an increase in the likelihood of consumers being referred to acute services and a reduction of the likelihood of earlier discharge to a non-acute setting. We also identified an absence of strategies to support a system which builds the confidence of clinicians in supporting more consumers within a community based setting, such as: • • •

MH nurse practitioners in the EDs A comprehensive and ongoing cultural and change management program to achieve sustained change A targeted learning and development program focussed on four key outcomes: 1. Increased clinical competency in community settings to support higher acuity levels than exist today. This will ensure more consumers with a higher level of mental health acuity can be treated in a community setting rather than an acute hospital 2. Greater collaboration between staff from acute and non-acute settings 3. Better care pathways between EDs, inpatient services and community based services 4. Translation of innovation and best practice across the entire MH system

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Supporting evidence A study of the Comparator MH systems (refer to Appendix C) highlighted that: •

Interstate experience demonstrates a greater focus on staff training and development in MH services with responsibility split between the Department and LHNs: Department responsibility

►

►

LHN responsibility

•

►

Develop Mandatory criteria – aggression training, suicide prevention, etc that is delivered through training that must be undertaken on an annual basis Provide limited funding Fund and implement locally a “reflective practise” model for nursing delivered through the use of an external consultant

►

Include training budgets in operational budget for MH unit

►

Implement a clinical supervision model that is across all of the LHN MH services

►

Interpret and deliver a central training policy/guidance to suit the local needs

►

Establish performance plans

►

Support staff to complete MH post-graduate studies e.g. weekly study leave allowance

Workforce capability is considered by the Alfred senior clinicians, Victorian Health care executives and clinicians in general to be a critical success factor in the Alfred MH service in Victoria. The Alfred MH Service developed a training framework that is embraced, coordinated and enforced by the psychiatry clinical and management dual leadership team. The program is supported by the Alfred Health Service Executive and is used to support the Non Government Organisations (NGO) relationships through joint training and opportunities for secondments. The framework includes a range of mandatory and recommended training models. The following list covers the elements that are considered to be mandatory: Training required annually includes

►

Emergency Training

►

►

Hand Hygiene

►

►

Falls Prevention

►

Clinical Handover

►

Medication Safety

Training required once-off during orientation period includes

• •

Mandatory Training Day – recovery framework, carer/ consumer engagement, ethics/ gender safety/ confidentiality/ MSE

►

Basic Life Support

►

Safe Moves

►

Training required every two years includes

SCAM for nurses that single check injectable medications

Outcome measures e.g. Health of the national outcome scales

►

Suicide and Risk Assessment Training

►

DAMA Inpatient (de-escalation training)

►

Community De-escalation and Management of Aggression training

►

Health Service Orientation to Mental Health Act/ local practice

►

MHpod Suicide Training

►

Psychiatry Orientation - Nursing

►

Psychiatry Orientation - Allied Health

►

Dual Diagnosis Training

►

Inpatient Day 1 De-escalation and Minimisation of Aggression

►

Physical Health Monitoring

MH nurse practitioners are an integral part of the effectiveness of acute flow of MH consumers and more effective and rapid discharge to alternative settings The National Institute for MH in England outlines principles for training and capability development regarding personality disorders. These state that training should: • Be based on respect for the human rights of service users and their carers • Include programs which best reflect the service users’ and carers’ views and experiences

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• • • • • •

Be aimed at breaking the cycle of rejection at all levels including self-rejection, the social support system, practitioners and the health and social care systems Encourage patient/client autonomy and the development of individual responsibility Be multi agency and multi-sectoral Support team and organisational capacity as well as that of individual practitioners Include programs which are connected to meaningful lifelong learning and skill escalator programs Promote learning in treatment and care that is supported by research evidence, where it exists

Recommendations Recommendation 1: Design and deliver a comprehensive change management program to implement the remaining reform focussing on the priority recommendations in this Review. Recommendation 2: Develop a new function in ED delivered by MH nurse practitioners to optimise timely admission/discharges through changes to the acute care pathway and medical/nursing delegations. This recommendation along with other measures outlined in recommendations 7, 8 and 9 should also reduce seclusion and restraint rates. Recommendation 3: Design and deliver a training and development plan for MH staff in acute, non acute and in support areas such as Ambulance, Police and Correctional Services. A strong training and development program implemented in tandem with improved protocols and standards between services will support a more optimal service mix, achieve a better balance between acute and non-acute care, and deliver services to consumers at the most appropriate level of care. The training modules required would aim to: • • • • • •

Reduce stigma and discrimination around MH consumers Raise awareness in how to support someone who may have an acute mental illness e.g., ED, MH, police and ambulance staff Deliver mandatory MH training for all ED staff, including consumer/carer participation Develop skills aimed at enhancing a balanced risk appetite, multidisciplinary interactions and consistent standards/ processes Support advanced team supervision and mentorship models across all MH teams including areas such as profession supervision and preceptor mentorship Translate skills acquired from training into practice through the LHN’s communities of practice and a reflective practice model

Recommendation 4: Consider how the content from third parties (such as the Victorian Department of Health and in particular the Alfred Health) can be leveraged in designing the training and development programs. Some adaptation may be required however this is likely to be minimal.

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Question 3: Are there sufficient adult acute inpatient beds available in the SA MH system? Findings Based on data provided by the Department, there are 22.3 adult beds per 100,000 of population in SA. This includes state-wide beds which are used for purposes beyond the specific catchment area of the SALHN (i.e. whole of State such as Veterans). Sufficient adult acute inpatient beds are available in the SA MH system. However the answer is not as simple as ‘yes’ or ‘no’ as indicated below, given the challenge in comparing across states, the imbalance between acute and non-acute services and the rate of reform. It is extremely difficult to undertake absolutely valid comparisons of inpatient beds between States. Each State has subtle but important differences in how they count, what they include and the definition of what should be included. However, in SA it is appropriate to include state-wide and Repatriation Hospital beds when the bed numbers for the State are compared with the national average. The Review found that of the 24 beds at the Repatriation Hospital, 13 are used by veterans. The remaining 11 beds are available for adult use in SALHN. No standard way exists to calculate Veterans’ MH beds as in many states Veteran acute services are provided in the private sector. In addition state-wide services are provided in different ways depending on the State, however for the purposes of comparison the review believes that the national average acute bed comparisons are valid. We also note in each state there are differences in the balance of services impacting the acute and non acute balance, which makes accurate interstate comparisons difficult. The qualification about bed numbers is provided in light of the current imbalance between acute and non-acute services in SA. It is not simply a bed numbers issue. Rather it is the under development of an evidence-based community model of care with effective upstream acute care reductions and mobile/rapid provision of intervention and alternatives to ED and inpatient bed based options. Having the right numbers and type of staff with the required training to deliver effective care is also essential. Recognising the Stepped Up reforms are not operating yet in full, the Review team understands there are current plans to increase bed capacity across SA as follows: • •

• •

Two 10-bed Community Rehabilitation Centres in country in 2014 with COAG funding - 20 beds The 4th ICC planned in the northern area in 2014 (funding to be identified) – 15 beds. Note that we do believe the ICC is necessary but should not commence until a resource reallocation model has been initiated (refer Recommendation 11) and appropriate resources identified through this mechanism Country beds will increase over the next 12-18 months with 10 Limited Treatment Centre beds COAG National Partnership Agreements will provide for 159 beds additional and places by 2014 (69 facility based beds and 90 non facility places in metropolitan and country) 10 new additional beds are to be added to James Nash House in mid 2014

The data relating to national financial comparisons suggests that additional funding for the system is not required at this point in time other than to stimulate full implementation of the recommendations of the Stepping Up report. It is anticipated that it will take up to 12 months to progress this and at this time a reassessment of bed capacity can be made.

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Supporting evidence The current allocation of beds per 100,000 population (18-64 yrs) and comparisons to the national 1

average for adult acute and residential 24/7is as follows : Grouping

Including

Total number beds

Beds per 100,000 population

Social housing

N/A

Supported accommodation

Metro

Residential 24/7

243

24.6

N/A

59

6.0

N/A

CRC, ICC (excluding nonFacility beds in Country), Burnside HASP

125

12.7

6.0

Adult Acute

Hospital (Inpatient) plus statewide beds.

220

22.3

24.3

Secure

Glenside

40

4.0

N/A

James Nash and Glenside

40

3.2

N/A

Forensic

2

National average

The comparative data analysis to national averages indicates that: • Per capita spending on MH by SA is above the national average at $167.25 versus the national average of $151.63 • The national average for Adult Acute beds was 24.3 beds per 100,000 of population compared to SA at 22.3 beds per 100,000 of population (2013 MH Services in Australia Report - 2010-11 data). • SA has a higher level of residential 24/7 beds than the national average at 12.7 beds per 100,000 population versus the national average of 6 beds • SALHN is well provisioned with acute beds compared to other LHNs even excluding state-wide beds • It is noted that there is pressure on other beds (eg; secure) and this is being addressed through the ongoing Government initiatives described on page 8 of this report. • The major concern with bed access and ED waiting time has been at SALHN yet the acute bed numbers are greater on a population basis than other LHNs

Recommendations Recommendation 5: Close no further adult acute beds in the MH system until a greater acute/non-acute balance is achieved and the ‘flexing’ of SALHN MH inpatient beds is stabilised. This should be achieved within 12 months. Flexing is a local SA Health term used to describe the action of opening and closing an inpatient bed according to consumer demand and available clinical staff. Recommendation 6: Re-assess the bed capacity once the Review recommendations are underway (including the introduction of further planned and funded Stepping Up initiatives outlined herein) with the intent of further shifts in resources to non acute services and to better balance resources between LHNs. This process should take up to 12 months at which point a migration plan can be finalised with the appropriate Departmental resource support.

1 2

Figures provided by Department in May 2013 18+ years (not just 18-64)

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Question 4: How can ED function better for MH Consumers? Findings A range of issues were identified with ED operations through Royal Adelaide Hospital and Flinders Medical Centre staff and consumer consultations. The comparator analysis presented solutions which would improve the management of MH presentations to EDs in SA. The comparator analysis of Alfred Health highlighted considerable improvement is possible through a range of initiatives including: • • •

Training and development program as previously discussed Introduction of more nurse practitioners Clear agreements and protocols between inpatient wards, EDs and community based services

Improvement in other jurisdictions relate to the reduction in the use of seclusion rooms through: • A strong use of MH nurse specials (one on one allocation of nurse to consumers) • Some use of security contracted and in house security guards • Robust and understood acute sedation protocols in the ED • Active review of patients by the client assessment team clinicians. A priority is placed on finding these patients a bed in a mental health inpatient facility rather than in ED. This means that consumers are just not left in ED and seclusion rooms in ED. They are actively managed to a bed on the basis that ED is not an appropriate location for them. South Australia reports high rates of seclusion and restraint. The positive work of the Mental Health Unit of the Department and the sector in general in reducing seclusion rates in South Australia is acknowledged. Notwithstanding, Victoria has achieved significant reductions in both the use of seclusion and also restraint through the use of nurse practitioners (with appropriate delegations) and implementation of a range of measures indicated in recommendations 7, 8 and 9.

Supporting evidence Improvement in ED functions have been demonstrated by Alfred Health which: • • •

Meets the 4 hour ED target for MH consumers Has significantly lower restraint rates in the ED Admits a much lower proportion of MH presentations from the ED

Differences are significant and contribute to the ED’s level of performance: Assessing the patient • A MH assessment is undertaken as soon as possible i.e. the consumer does not have to be under 0.05 on the blood alcohol scale. A risk assessment is always undertaken, as soon as they are conscious and coherent. • Parallel assessments by MH and General ED and the ‘clock starts ticking’ as soon as a consumer is triaged. The triage nurse notifies the MH team • Known consumers will have a detailed MH plan that includes a care plan for when they present to the ED. This helps reduce readmissions Behaviours of concern (BOC) • •

There is a specific BOC strategy which the MH team led the development of. This strategy extends to patients that don’t have a mental health issue, but display BOC When consumers with BOC present to the ED, the mental health team and an ED consultant will meet them at the door. Immediate parallel assessments are done to ascertain the plan

Training and development • The MH team take a lead role in developing and conducting training for staff from ED and across the health service

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Advanced practice models • • •

A nurse practitioner in the ED can prescribe and commence treatment and discharge the consumer if the issue not complex A nurse admits or sends consumers home from the ED, underpinned by a mandatory competency framework MH Hospital Admission Risk Program aims to reduce the consumer’s readmission

Recommendations Recommendation 7: Develop and apply a consistent ED/MH Team set of triage criteria and protocols. A consistent set of protocols would include: • The need for parallel assessments to reduce time in the ED • Criteria for when a general medical clearance is required • Business rules including ‘starting the clock’ upon presentation at the ED • Process for escalating risk behaviours e.g. Drug and Alcohol presentations • The use of restraints, based on actual security risk Recommendation 8: Design and implement a system within ED to alert MH teams of repeat consumers so they can be more actively managed to reduce incidence of ED contact in the future. This system should include the development of procedures to support an escalation of a case review for known clients re-presenting multiple times e.g. 3 times in a month; 6 times in 6 months. Recommendation 9: Establish an ED/MH team liaison meeting with a Terms of Reference to monitor the advancement of practice development, practice change and outcome monitoring. Recommendation 10: Consider the development of local telephone triage assessment with an underpinning competency framework connected to Community Mental Health Teams (CMHTs). This could be co-located with community residential respite, may include a counselling service and will have local knowledge of consumers. Any remaining state-wide triage will operate to relate to other state wide services e.g. Police and Ambulance and to internally connect call to local telephone triage service.

Question 5: Should the catchment areas for LHNs and the MH system catchment areas be the same? Findings The MH system and LHN catchment areas should be the same in order to provide services closest to the consumer’s home and to better coordinate with all providers in future service planning. In some instances consumers are being referred to LHN services which are a great distance from where they reside when an alternative LHN is closer. Unley is a case in point which is currently serviced by SALHN when it could be by CALHN. However, in the future, service planning efforts must also consider primary care (Medicare Local) catchments in order to provide a better understanding of resource allocation and future demand for services. It is also noted that there appears to be a significant disparity in the way staff resources are allocated in SALHN compared to other LHN’s. Issues in respect to this disparity and potential reallocation of staff from SALHN’s acute to non acute services are discussed in Question 6.

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Supporting evidence The current staff profile for adult MH services across LHNs is presented below, illustrating the disparity in staff resources across the LHN’s. Service Setting

Data

Admitted Patient – Acute

Medical

37.0

22.15

12.57

7.6

79.29

Nursing

148.3

130.07

67.92

27.47

373.75

11.9

9.42

7.89

2.5

31.68

Allied Health

Total

10

0

0

10.00

0.6

2.3

1.93

2.5

7.33

14.6

11.43

3.5

2

31.52

212.3

185.37

93.81

42.07

533.57

Medical

3.61

3.61

Nursing

71.67

71.67

Allied Health

5.14

5.14

Domestic & Other

27.9

27.9

Other Personal Care

6.93

6.93

11.72

11.72

Total

0

126.97

0

0

126.97

Medical

0.83

2.45

0

3.28

Nursing

21.16

42.53

5.27

68.96

5.54

6.36

4.23

16.13

Allied Health Domestic & Other

0

5.16

0

5.16

Other Personal Care

14.3

17.11

8.25

39.66

Admin

2.19

7.61

0.93

10.73

44.02

81.22

18.68

0

Total

143.92

Medical

18.8

35.1

18.74

12.29

84.93

Nursing

98.11

120.66

60.91

97.11

376.79

Allied Health

50.77

63.36

32.36

44.22

190.71

0

0

0

0

0

Domestic & Other Other Personal Care Admin Total All direct care staff

Country LHN

0.0

Admin

Community

NALHN

Other Personal Care

Total

Residential

CALHN

Domestic & Other

Admin

Admitted Patient – Non-acute

SALHN

5.29

2.82

1.64

12.36

22.11

11.97

19.08

14.26

23.52

68.83

184.94

241.02

127.91

189.5

743.37

441.3

634.58

240.4

231.57

1547.83

Notes: • • • • •

Data source: MH Establishments NMDS 2011-12 (unpublished) as per expenditure data SALHN admitted patient staffing figures contain FMC services for Ward 4G (state-wide Eating Disorder and Gambling services) combined with Margaret Tobin Centre services SALHN community staffing figures include state-wide Eating Disorder, Gambling and Anxiety services, and Veterans services CALHN admitted patient staffing figures contain RAH Psychiatric Extended Care Unit (PECU)staff combined with other RAH and Glenside adult acute services Note that some LHNs have larger number of beds and facilities and this impacts on the figures

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Recommendations Recommendation 11: Align the LHN and MH catchment areas. The Department should run a population and needs resource reallocation model to rebalance resources between LHNs based upon their population coverage and service need. The reallocation process should be phased over time to ensure that LHN’s can accommodate the change.

Question 6: Is there a need to reallocate staff within the SALHN? Findings There is a significantly higher level of medical staff and a slightly higher level of nursing staff in SALHN’s acute services and conversely a lower level in non-acute services compared to other LHN’s. In light of the need to improve the risk adverse culture of community mental health services and reduce the need for consumers to be referred to ED and inpatient services in SALHN, a reallocation of some FTE for medical staff appears warranted. It was not in the brief of the Review to undertake a detailed workload versus FTE analysis, but on the available data between 3.0 and 5.0 FTE medical staff could be reallocated within SALHN. The reallocation should reflect the staffing levels needed to resource the model that can deliver on three key functions of: 1. Acute community care 2. Assertive Community Treatment 3.

Standard Case management

Based on the current level of resourcing per capita this reallocation will not require any additional funding, but requires a more detailed analysis of the structure and staffing of Community MH teams: • Community assessment and acute treatment teams These teams provide crisis intervention and home treatment (upstream) to divert pressure away from ED/Inpatient beds. The evidence (from the Alfred Hospital) supports a ratio of staffing of 15 per 150,000 head of population including a psychiatrist embedded/integrated in the team •

Assertive Community treatment teams This is to target the most frequent presenters with complex issues and high level of needs. An agreed population ratio should be developed as the basis of determining the staff to consumer needs.

•

Standard case management This element of care should be based on a caseload of 25 to 30 based on the Alfred Hospital comparator. Reallocation numbers should reflect the staffing levels needed to resource the model that can deliver on key the three key functions.

Supporting evidence The current staff profile for Adult MH Services across LHNs was mentioned previously in Question 5, illustrating the disparity in staff resources across the LHN’s The Comparator Analysis verifies this finding by comparing SALHN staffing mix with that of the Alfred acute network. We acknowledge that comparisons with interstate services can be difficult (in light of different counting methods and service mix), however the medical staff differential is notably high.

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The table below indicates that the Alfred acute network has 12% of its staffing as medical. SALHN has 17% of its staffing as medical. It is also worth noting that there are more Allied Health staff at the Alfred (12% versus 5.6%) and about the same nursing mix, although there are no Nurse Practitioners at the SALHN. Staff mix

Alfred Health

SALHN

Medical

12.0%

17.0%

Nursing

73.0%

70.0%

Allied Health

12.0%

5.6%

Other

3.0%

7.4%

Total

100%

100%

The table below indicates that the Alfred is a reasonably comparable Health service in terms of population served and the number of acute beds in which to draw a conclusion of the imbalance of medical FTEs for admitted acute MH patients. Comparison Data Population served Inpatient beds - Acute -

Alfred Health

SALHN

430,000

340,072

58

55

Data was drawn from comparator Health Service, Alfred Health (with 101.2 acute FTE) and presented in comparison to the SALHN FTE Split.

Recommendations Recommendation 12: Change the nursing skill mix for acute services at SALHN In respect to nursing staff the local LHN management should undertake a more detailed FTE analysis with the focus on achieving a different nursing skill mix in acute services at SALHN with the recruitment or training of MH nurse practitioners. This should be possible to achieve within existing establishments and existing resources. For nurse practitioners to be effective in altering the acute care pathway a change to delegations between medical and nursing staff will be necessary. Recommendation 13: Reallocate approximately 3-5 FTE from hospital based to community MH services Initiate a reallocation of FTE from hospital-based to community MH services in respect to medical staff at SALHN. This reallocation should also support the development of a small early intervention/1st episode psychosis team within CMHTs. Based on our analysis there are at least 3.0 – 5.0 FTE in medical staff that could be reallocated. The reallocation should be staged in order to ensure that services can plan for changes in an orderly manner.

14 | EY


Question 7: Who should operationally manage MH Services including bed triage and allocation of patients to LHNs? Findings The LHNs should operate the MH Services. The level of operational devolution in Victoria allows for clarity around the level of accountability that is placed on the health service. With respect to MH services many of the elements that contribute to the success of this service at Alfred Health are achieved because of the autonomy allowed to make local decisions regarding operational matters. Coupled with this autonomy, are clear expectations around outputs and outcomes. These are outlined in a Statement of Priorities (Funding and Services Agreement) to which the Board and Chief Executive are held accountable. In terms of the ED, MH teams are equally accountable for meeting the 4-hour rule. The management and clinical leaders in the MH team must report against this and are expected to address consumer discharges (with appropriate support) in order to allow consumers to move through the ED more effectively. More broadly, MH services and the resolution of MH issues are led by a partnership between the MH Manager and the Clinical Director. Protocols are in place in Victoria that address issues of consumer attendances from other catchment areas and sharing of bed capacity at times of high metropolitan activity.

Supporting evidence The interstate comparator is notably different. All other clinical services other than MH services are operationally managed by LHNs. While there is a theoretical benefit in managing beds on a statewide basis to ensure maximum efficiency and effectiveness in bed use, in practice this outcome is not achieved. Failure to manage locally reduces local accountability and encourages practices to hold consumers in beds for longer than necessary to protect capacity for future patient referrals. At one of our site visits staff openly stated that occurs.

Recommendations Recommendation 14: The LHNs should operate the MH Services. Redefine the role and accountability of the Department and the LHN’s such that LHNs have full operational accountability and responsibility for MH service delivery. This should include: • • • •

Agreement and communication of the role of the Department in an operationally devolved MH system An increased contracting function for the Department and system planning functions focussed on improved service delineation Development of the performance management framework for MH Services with closer integration of key performance indicators into Service Agreements with LHNs. Establishment of a state-wide benchmarking and reporting service to improve transparency and data quality

Recommendation 15: Review the required change in FTE for the MH Unit of the Department in light of the changes in LHN accountabilities.

15 | EY


Question 8: What should be the reallocation of resources between LHNs? Findings A clear need exists to reallocate some resources between LHN’s. Catchment area realignment will require this as a matter of course and this was discussed earlier with an appropriate recommendation. However, there is a clear disparity in resources for NALHN versus others, and in particular the SALHN. NALHN have no ICC beds, lower supported accommodation and lower acute inpatient beds. Justification exists in reallocating resources in CALHN and SALHN to support further NALHN services and in particular the Northern ICC and North Eastern CMHT. It is also noted that SA has a higher ratio of beds per capita for Residential 24/7 beds (6.0 vs. 12.7) yet the NALHN is significantly under-provisioned in this regard. This also suggests an opportunity exists for reallocation between LHNs. However, in light of the fact that the SA MH system is adequately funded by national comparison, then this should only occur through a resource reallocation process. It is important to be much more precise than a high level analysis. Modelling based on population and service need is possible and this should be undertaken as an additional requirement to the catchment area realignment. The inclusion of country patients in metropolitan facilities makes this process all the more important as estimates may be inaccurate.

Supporting evidence Acute bed comparisons supporting our findings are provided below: Table 1 - numbers per 100,000 across each LHN and across the Stepped Model of care Area Social housing

NALHN

CALHN

SALHN

Country LHN

28.6

24.7

23.5

22.0

Supported accommodation (Metro)

4.4

10.0

10.4

N/A

CRC

8.8

7.4

9.4

0

0

11.1

7.1

7.2

20.3

23.2

25.9

8.3

ICC** Hospital (Inpatient/ Adult Acute)*

*Excludes access to State-wide beds e.g., Repatriation General Hospital. ** - Non-facility beds.

Recommendations Refer to Recommendation 11.

16 | EY


Appendix A

Scope and approach

EY was engaged by the Department for Health and Ageing, South Australia (SA) (the Department) to deliver the first phase of a Review of the South Australian stepped system of MH care and capacity to respond to emergency demand (the Review). The driver for the Review has been has been recent pressure within some emergency departments (ED) in respect to acute patient flow. The Southern Adelaide Local Hospital Network (SALHN) was specified in the terms of reference for the Review, with the perception that performance against access targets is being predominantly impacted by sub-optimal mental health (MH) consumer flow management and the balance or otherwise of acute versus non-acute MH services. The specific areas of focus for the Review included: • • • •

An assessment of the capacity and processes of the (SALHN) to effectively manage acute demand and examine waiting times in the Flinders Medical Centre ED An assessment of bed coordination and patient flow practices, and examine the practices and processes underpinning emergency MH responses across the State An assessment of the balance of acute and non-acute MH services as a result of SA Health’s Stepping Up MH reforms A desktop review of the basis and assumptions of the Stepping Up recommendations and how they compare with current evidence based practice

The brief and time frame for the Review did not extend to a full review of the entire MH system in SA. The scope of the Review has included: • The delivery of an independent report with recommendations in relation to the four areas within scope for the Review only • A focus on SALHN ED performance issues related to MH consumers. Whilst the Review brief largely focussed on acute demand issues, it has been necessary to examine many areas of the MH system beyond this in order to determine key causes of acute demand problems. However, this did not extend to a detailed analysis of areas beyond the brief • A predominant focus on SALHN models of care, teams and patient flows and on Adult MH Services only i.e., excluding 0-18 yrs or 65+ yrs • Although it has been necessary to examine the impact of Forensic MH Services demand upon the acute system, the Review has also not focussed directly on Forensic MH Services • A focus on the 15 recommendations in the Stepping Up report related to ‘Implementing a stepped system of care with community services at its centre’ only – recommendations six through to 20 • Quantitative analysis using data readily available and provided by SALHN, the Department or where publically available. EY has not verified the accuracy of the data and where discrepancies have been identified between data sources we have relied on the Department’s data • A rapid comparison of 2 other Australian jurisdictions, but mainly limited to Victoria The Review was based on a desktop review of key literature, analysis of data/information and completion of a series of structured stakeholder consultations and a limited interstate service comparison. Nearly 30 separate stakeholder consultation events have been completed with a mix of one-to-one interviews, group workshops and site visits. A full list is included In Appendix B.

17 | EY


Appendix B

Stakeholders consulted

The following stakeholders have been consulted during this Review. No

Organisation

1

AMA

2

ANMF SA

3

PSA

4

Senior ED staff of Royal Adelaide Hospital

5

LHN Mental Health Clinical Directors and General Managers

6

ANMF SA (Group consultation)

7

Professional Organisations and Unions (group consultation)

8

Chair State-wide Mental Health Clinical Network

9

LHN CEOs

10

Public Advocate

11

Independent Psychiatrist - Ross Kalucy

12

Women’s & Children’s LHN Clinical Directors and MH GMs

13

Community Visitor & Health Complaints Commissioner

14

Clinical Senate Executive

15

Senior ED staff of FMC (including tour of ED)

16

FMC Mental Health Inpatient staff

17

Police/Ambulance/ Corrections

18

Consumer & Carer workers (Group session)

19

Consumers & Carers (Group session)

20

NGO’s and Peak Bodies, including MH Coalition and Health Consumers Alliance

21

Mental Health Sector Managers

22

Inner Southern Community Mental Health teams

23

Noarlunga/Outer South MH (ED, MH Inpatient, ICC, Community MH teams)

24

Southern and Central Medicare Locals

25

NALHN Clinical Director

26

Dr Peter McGeorge, St Vincent’s, Sydney

27

Country Mental Health (Group consult)

28

Mental Health Carers (Bob Burke and group submission)

29

Mental Health Bed Co-ordinators

18 | EY


Appendix C

Comparator MH systems

The Review has considered comparator MH systems in NSW and Victoria, but in particular the Victorian MH system through a focus on Alfred Health in Melbourne. Victoria and Alfred Health Alfred Health is the main provider of health services to people living in the inner southeast suburbs of Melbourne and is a major provider of specialist state-wide services to the people of Victoria. Alfred Health covers a population of approximately 400,000 with a high degree of transience and homelessness. The Alfred Hospital ED attends to approximately 57,000 emergency patients annually, the majority being higher acuity with approximately 50% of patients presenting require admission to hospital. Key elements of MH service provision at Alfred Health and relevant to this Review include: Governance, ownership and accountability

When considering Alfred Health as a comparator service it is important to remember the governance structures that underpin the Victorian heath system. Victoria has a long established system of devolved governance for health service operational delivery. Victorian health services are incorporated public statutory authorities and are positioned at arm’s-length from the government and have separate legal status. This level of devolution allows for clarity around the level of accountability that is placed on the Boards governing the health services. With respect to MH many of the elements that contribute to the success of this service at Alfred Health are achieved because of the autonomy allowed to make local decisions regarding models of care, staffing structures, and seeking own-source revenue. Coupled with this autonomy, are clear expectations around outputs and outcomes. These are outlined in a Statement of Priorities (Funding and Services Agreement) to which the Board and Chief Executive are held accountable. In terms of ED, MH teams are equally accountable for meeting the 4-hour rule. The management and clinical leaders in MH must report against this and are expected to address consumer discharges (with appropriate support) in order to allow consumers to move through ED more effectively. More broadly, MH services and the resolution of MH issues are led by a partnership between the MH Manager and the Clinical Director. Experience from Victoria also confirms the importance of consistent leadership, or at least consistent direction, throughout the MH reform journey.

Access, pathways, flow and diversion

Alfred Health consistently meets the 4 hour ED target for MH consumers, has significantly lower restraint rates in ED and admits a much lower proportion of MH presentations from ED. The MH team ‘pull’ their consumers from the ED in order to achieve this, the following is imperative:

19 | EY

►

Parallel assessments are undertaken (MH and General ED) and the ‘clock starts ticking’ as soon as a consumer is triaged. In these instances the triage nurse will always alert the MH team.

►

There is a specific ‘behaviours of concern’ (BOC) strategy which the MH team led the development of. This strategy extends to patients that don’t have a MH issue, but display BOC.

►

For example, when consumers and clients with BOC present to ED, via Police or Ambulance, MH and an ED consultant will meet them at the door. An immediate joint


assessment (high level) is undertaken to ascertain the best course of action. In addition, the MH team take a lead role in developing and conducting training for other members of staff in the ED and across the health service. ►

A MH assessment is undertaken as soon as possible i.e., the consumer does not have to be under 0.05 on the blood alcohol scale. A risk assessment is always undertaken, as soon as they are conscious and coherent.

►

There is a nurse practitioner in ED who can prescribe and commence treatment and discharge the consumer if the issue not complex.

► Known consumers will have a detailed MH plan that includes a care plan for when they present to ED. This helps reduce readmissions. ► There are also advance practice models where nurses can admit or send consumers home from ED. This is underpinned by a competency framework for the nurses to meet before they can assume that responsibility. More broadly, MH Hospital Admission Risk Program teams are in place. These are designed to reduce the readmission of MH consumers, which includes borderline personality disorder or any frequent users of acute services. Workforce and culture

There is a significant focus on staff training and development across MH services with responsibility for this at the system leadership / management and LHN levels. It is the Department’s responsibility to develop mandatory training criteria – aggression training, suicide prevention, dual diagnosis etc - which are met through training that must be undertaken on an annual basis. The Department also provides limited funding for the purposes of training and development. It is the LHNs responsibility to: ►

Deliver locally interpreted central training policy/guidance to suit local needs.

►

Include training budgets in the operational budget for MH unit.

►

Make local decisions to fund and implement a ‘reflective practice’ model for nursing delivered through the use of an external expert consultant.

►

Deploy a clinical supervision model that is across all MH teams.

►

Ensure nurse practitioners are also responsible for the training ED staff.

In addition, Alfred Health supports staff to complete post graduate studies in MH through the allowance of weekly study leave etc. Partnerships

20 | EY

Partnerships have been critical to achieving reform of the MH system over the years. Key aspects of this have included: ►

A formal partnership alliance panel with the NGO players in the region (and LHN).

►

Service co-location for clinical and NGO services.

►

Joint training with NGO staff and reciprocal secondments (NGO staff and LHN staff).

►

NGO housing and employment services being located within the clinical programs both within community and inpatient settings.

►

Psychiatrists conducting outpatient clinics within NGO settings for clients’ case managed by the NGO.


Appendix D

Glossary of terms

Abbreviation

Term

CALHN

Central Adelaide Local Health Network

CAT

Crisis Assessment and Treatment

CoAG

Commonwealth of Australian Governments

CMHC

Community Mental Health Centre

CRC

Community Rehabilitation Centre

ED

Emergency Department

FMC

Flinders Medical Centre

HASP

Housing and accommodation support partnership

IAPT

Improving Access to Psychological Therapies

ICC

Intermediate care Centre

LHN

Local Hospital Network

LoS

Length of Stay

MH

Mental Health

MoU

Memorandums of Understanding

NALHN

Northern Adelaide Local Health Network

NHS

Noarlunga Hospital

NMDS

National Minimum Data Set

PECU

Psychiatric Extended Care Unit

PICU

Psychiatric Intensive Care Unit

RAH

Royal Adelaide hospital

SDH

Social Determinants of Health

SA

South Australia

SALHN

Southern Adelaide Local Hospital Network

21 | EY


Appendix E

Reference documents

No.

Document

Date

1

Stepping Up: A Social Inclusion Action Plan for Mental Health Reform 2007 - 2013

2007

2

South Australia's Mental Health and Wellbeing Policy 2010 - 2016

2010

3

Chief Psychiatrist of South Australia Annual Report 2011/ 2013

2011-12

4

ADELP data 1 page 5/04/12 - 14/05/13

2012-13

5

PPRC March 2013 - Mental Health Indicators summary data (7 pages)

March 2013

6

Fourth National Mental Health Plan 2009-14 – Principle: Consideration of the spectrum of mental health, mental health problems and mental illness and Priority Area 3: Service, access, coordination and continuity of care.

2009

7

National Standards for Mental Health Services 2010 - Standard 10: Delivery of Care.

2010

8

Royal Australian and New Zealand College of Psychiatrists Principles to underpin effective mental health service delivery to the community 2012.

2012

9

NHS Emergency Services Review 2009 – Part 10, Good practice in delivering emergency care: mental health.

2009

10

NHS 10 High Impact Changes for Mental Health Services 2006 – Change 1: Treat home based care and support as the norm for delivery of mental health services; and 9: Optimise service user and carer flow through an integrated care pathway approach.

2006

11

Recording of Interview with NHS Dr Michael Rosenberg

2006

12

MHSA_org_Chart_Position_Titles

unknown

13

Australian Institute for Social Research, 2011, Evaluation of the Three Community Rehabilitation Centres - Final Report

May 2011

14

Health Outcomes International, 2011, Evaluation of the Individual Psychosocial Rehabilitation & Support

May 2011

15

A submission by the Inner South Psychiatrists, Flinders Medical Centre, SA - Executive Summary - Do 2012 we have enough General adult acute psychiatry inpatient beds in South Australia?

16

A submission by the Inner South Psychiatrists, Flinders Medical Centre, SA - Acute beds submission final version 100912 - Do we have enough General adult acute psychiatry inpatient beds in South Australia?

2012

17

letter to Minister from Consultant Psychiatrists (Inner Southern Region) 21-05-2012 + appendix 2012

2012

18

Ministers response to AMA Nov 2012.doc

2012

19

Inner South Psychiatrists Response to DOH.docx

unknown

20

Rosen et. Al, Chapter 16 - The Human Rights of People with Severe and Persistent Mental Illness, May 2012

2012

21

Alan Rosen, (2012),"Mental Health Commissions of Different Sub-species: can they effectively propagate mental health service reform? Provisional taxonomy and trajectories", Mental Health Review Journal, Vol. 17 Iss: 4 pp. 167 - 179

2012

22

Rosen et al, 2007, Assertive Community Treatment—Issues from scientific and clinical literature with 2007 implications for practice, Journal of Rehab Research and Development, Volume 44, Number 6, 2007

23

Siskind et al, 2012, Planning estimates for the mental health community support sector, Aust N Z J Psychiatry-2012-Siskind-569-80

24

Harris et al, 2012, Planning estimates for the provision of core mental health services in Queensland 2012 2007 to 2018, Aust N Z J Psychiatry-2012-Harris-982-94

25

Bastiampillai et al, 2010, Implications of bed reduction in an acute psychiatric service, MJA 2010; 193: 383–386

2010

26

Ben-Tovim, 2012, FMC performance over time (fmc_nhs_ed_mh_los_weekly_report)

Various

27

Stepping Up Status Report March 2013

March 2013

22 | EY

2012


No.

Document

Date

28

Census of Population and Housing, 2011, Health Intelligence Population data

2011

29

Map - Mental Health drug and alcohol services in Country health

Jan 2013

30

Map -MentalHealthMetro_A3

Jan 2014

31

Mental Health Coalition Letter to Minister

March 2013

32

Mental health services - website dump

unknown

33

PPRC_Mental_Health_Reporting_201304April_V1

2013

34

Tolkien 2 extract

2010

35

Various data provided by SA Health: 07a_ED_Visits_Completed_Within_4_and_8_Hours 07a_ED_Visits_Completed_Within_4_and_8_Hours_Revised_Excl_DNW 07b_ED_Visit_Time 07b_ED_Visit_Time_Revised_Excl_DNW 08_to_09_Mental_Health_ED 12_Mental_Health_ED_Frequency 13_to_17_Mental_Health_ED 13_to_17_Mental_Health_ED_Month 01_to_06_Mental_Health_ED 01_to_06_Mental_Health_ED_Month 03_Total_Presentations_ED 06_Mental_Health_ED_Month_Arrival_by_Hospital 07_Wait_Time_From_Request_to_Admission__Rolling_12_months_new MinisterialReview_SALHN_201213_BudgetV01 MinisterialReview_NALHN_201213_BudgetV01 MinisterialReview_MHE_NMDS_StatewideSummary_201011_201112_V01 MinisterialReview_MHE_NMDS_201112_V01 MinisterialReview_MHE_NMDS_201011_V01 NALHN_201213_BudgetV02

Various

36

Presentation _ External Review NSW PECC _ Dec 2012

Dec 2012

37

NACMH 2010 _ Collab Care Models Adult Severe MI _ Report

2010

38

Criminal Law Consolidation Act - notes

1935

39

Draft Forensic Exec Group Terms of Reference April 2013 v2

2013

40

DRAFT FMHS Executive Work Plan 2013 v2

2013

41

SA Health Guidelines for Management of Forensic Patients in the Emergency Department Setting.pdf unknown

42

LGU advice request - Forensic MHS Apr 2013 v3

2013

43

RAH ED MHS Review OCT 11

2011

44

Community Admissions 2010_2012

2010-11

45

Governance proposal for Metro MH Directorate.pdf

Not available (N/A)

46

Governance arrangements Metro MH Directorate

N/A

47

OOS 13-11 Governance Changes AMMHD combined.pdf

N/A

48

Email from Malcolm Battersby regarding MH Org Structure

N/A

49

Org Structure sent by Malcolm Battersby

N/A

50

Rosen, A. - The future of community centred health services AHR Aug 2012

N/A

51

Rosen, A. - lessons from the mental health sector

N/A

52

AIHW - Mental Health Services Australia (report/web)

N/A

53

AIHW - Tables and data

N/A

54

AIHW - Mental Health Expenditure

N/A

55

Productivity Commission Report on Government Services 2013 - Chapter 12 Mental Health

N/A

23 | EY


No.

Document

Date

56

National Mental Health Report

N/A

57

Email from Julie Harrison - Review SA acute beds

N/A

58

GM Transitional Care Monthly Report March 2013

N/A

59

Transitional Care Program - Consumer Journey Team. Monthly report (Excel)

N/A

60

Memo to Exec Director MHSA_Proposal for additional funding for hospital avoidance

N/A

61

Residents admissions in the 12 months pre and post TCP

N/A

62

ICC Evaluation framework

N/A

63

Stepped System Review_13052013_v4

N/A

64

CRC Inpatient reduction data

N/A

65

GP Shared Care information provided by Mark Leggatt

N/A

66

GP Access Program information provided by Mark Leggatt

N/A

67

IPRSS statistics provided by Mark Leggatt

N/A

68

Housing and Accommodation Support Partnership (HASP) program - 1-page description of program

N/A

69

Reading the Consumer Activity Reporting System (CARS) reports

N/A

70

Financial Yrs HASP & IPRSS

N/A

71

HASP Hours July 2011 - June 2012

2012

72

HASP Hours July 2012 - March 2013

2013

73

IPRSS Hours July 2011 - June 2012

2012

74

IPRSS Hours July 2012 March 2013

2013

75

Letter to J.Birch re Forensics (from 7 Forensic Psychiatrists)

N/A

76

PSA - Brief notes on Stepping Up

N/A

77

SA-Mental Health Services in Rural and Remote South Australia

N/A

78

SA Review2008-Community-Mental-Health-Services-Rev-SA-08

2008

79

DBT Data Spreadsheet

N/A

80

Capacity Issues in the Forensic MHS

N/A

81

Letter to AMA - Forensics

N/A

82

DBT Achievements and evaluation

N/A

83

Restraints and seclusions

N/A

84

Care_Coordination_vMay1

N/A

85

090616 Model of Care - Final Draft_a2

N/A

86

25-1-2012 Business Rules Framework Version 17 SHORT (2)

N/A

87

Case_for_Mental_Health_Reform_in_Australia_-_Full_Report

N/A

88

PMHA Borderline Personality Disorder Hospitals Survey - Final Report

N/A

89

Borderline Personality Disorder report PMcE

N/A

90

Evaluation; Dr. Honeymans Service in NZ

N/A

91

ACISSAAS Emergency Response Project 2006

N/A

92

Acute 24-7 Clinical Business Rule v 10 LND

N/A

93

Briefing to the Minister re Court Liaison and Attachment 1 - Limited Trial of a Court Liaison Service

N/A

24 | EY


No.

Document

Date

94

National Institute of Clinical Studies (2006) Emergency Care Community of Practice: Mental HealthEmergency Care Interface Project 2004–2006 Report. NICS, Melbourne.

2006

95

Alfred Psychiatry Training Requirements Nursing and Allied Health 2013

2012-13

96

National Institute for Mental Health in England, Breaking the Cycle of Rejection - The Personality Disorder Capabilities framework

Nov 2003

97

NHS, National Institute for Mental Health in England, 2003, Personality disorder: No longer a diagnosis of exclusion Policy implementation guidance for the development of services for people with personality disorder

Jan 2004

98

Project Air Strategy for Personality Disorders (2010) Treatment Guidelines for Personality Disorders, NSW Health and Illawarra Health and Medical Research Institute, www.projectairstrategy.org

2010

99

Borschmann R, Henderson C, Hogg J, Phillips R, Moran P. Crisis interventions for people with borderline personality disorder. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD009353. DOI: 10.1002/14651858.CD009353.pub2.

2012

25 | EY

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