PART 3

RESPONDING TO PEOPLE IN PSYCHIATRIC CRISIS

INTRODUCTION

3.1 A psychiatric crisis occurs when an individual experiences a pronounced, negative change in functioning associated with their mental disorder. The crisis may occur within the context of a pre-existing mental disorder, or it may arise spontaneously in response to stress or trauma. Psychiatric crises are often associated with extreme levels of distress, high risk of suicide and/or harm to other people. For these reasons, a timely and appropriate service response is critical.

3.2 Public Area Mental Health Services (AMHSs) play a critical role in responding to people during a psychiatric crisis, particularly after-hours when other support services may not be accessible. Public AMHSs are required to provide assessment, treatment and support to people with “serious mental illness” and/or an associated level of psychological disability¹.

3.3 This Part of the report examines key aspects of the response to people in psychiatric crises, including:

• systemic issues relating to unmet service demand and work force requirements;

• service delivery framework, including service access, priority and timeliness;

• psychiatric hospitalisation, including particularly bed numbers, length of stay, involuntary admissions and discharge practices; and

• community-based treatment, focusing on case management, comprehensive assessment and individual service planning, access to information, treatment options and service linkages.

SYSTEMIC ISSUES

3.4 In this Part of the report we address system-wide issues which impact on the timeliness and appropriateness of mental health service delivery in Victoria.

Service demand

3.5 Demand for public mental health services in Victoria is increasing. Between 1997 and 2001, the total number of registered AMHS consumers increased by about 20 per cent. There has also been a 36 per cent increase in registered client contacts during the same period. Additional evidence of service demand increases include:

• Crisis Assessment and Treatment (CAT) team contacts have increased by 52 per cent across all public mental health services between 1997 and 2000;

• Psychiatric Disability Support consumer participants increased by 39 per cent between 1997 and 2000; and

• acute adult inpatient admissions increased by 7 per cent between 1997 and 2000².

3.6 Our review of the relevant literature indicates that factors which may be contributing to service demand increases include:

• population growth (up 1.15 per cent between 1997 to 2001);

• increased prevalence of mental health problems, especially depression and related disorders;

• improved professional and community recognition of mental disorder;

• a rise in the number of people presenting with multiple diagnoses, particularly co-existing mental disorder and substance abuse problems;

• increased demand for carer support services;

• increasing demand for psychiatric consultation from the acute health system, through greater recognition of the overlap between physical and emotional disorders; and

• limited availability of after-hours crisis response by other services, including alcohol and drug services, general welfare services, general practitioners (GPs) and private psychiatrists.

Evidence of unmet demand

3.7 Audit findings and Statewide data indicate a high level of unmet demand for mental health services in Victoria. Evidence for this conclusion comes from several sources:

• Data on the prevalence of mental disorders in the community indicate that 2 to 3 per cent of the adult population may have a severe mental disorder. If the figure of 3 per cent is compared with the number of registered service users, potentially up to one-third of people with a mental disorder meeting the AMHS target group are not receiving treatment from AMHS. In Victoria, this translates to about 40 000 people who may be accessing alternative mental health services such as GPs and private psychiatrists;

• A recent review of Statewide psychiatric inpatient services³ concluded that there is a significant shortfall in the current supply of psychiatric beds for people with serious mental disorders, and that the distribution of beds Statewide is variable;

• Accommodation and support options for people with a mental illness are severely limited. There is a Statewide shortage of residential and inpatient treatment options for consumers with dual diagnoses. After-hours services for homeless people with a mental illness are also in short supply;

• Lack of alternatives to inpatient services, including services for consumers at different stages of recovery, have been identified in focus groups conducted by the Department of Human Services;

• Statewide waiting list data indicates that there is a high unmet demand for community-based residential, rehabilitation and outreach support services for people with severe and prolonged mental disorders⁴. Waiting lists for all psychiatric disability support services increased by 118 per cent between 1998 and 2000. Waiting lists for home- based support services increased by 113 per cent during the same period⁵;

• Consumers and carers report a serious shortage of community-based mental health services for consumers with diverse and complex needs⁶; and

• An Australian study of psychotic disorders reports that “… there is a serious lack of, and need for, community-based rehabilitation programs for people with psychotic disorders”⁷.

Consequences of unmet demand

3.8 Increasing and unmet service demand is impacting negatively on the public mental health system at several levels:

• Audit observations suggest that discharge decisions are influenced by demand pressures, rather than based solely on clinical needs. There has been increased consumer “throughput” (bed utilisation) and reduced length of stay in hospital, thereby increasing the likelihood of future readmission. The Department’s New Directions plan, released in September 2002, notes the need to increase the capacity of acute inpatient services and for a demand management strategy;

• Audit data indicate that crisis response times have risen as a consequence of high demand, resulting in consumer distress;

• Carers interviewed during the audit and the Department expressed concern about the shortage of supported community-based services for consumers, and the significant burden this placed on families and carers creating a related demand for carer support services; and

• The need to focus on meeting current needs allows limited capacity for early intervention and/or prevention of mental disorders. This is a strategy outlined in the Department’s New Directions plan.

3.9 The impact of unmet demand is illustrated in Chart 3A.

Chart 3A
Causes and consequences of increasing service demand

Source: Victorian Auditor-General’s Office, 2002.

3.10 In summary, increasing service demand and associated levels of unmet demand are resulting in service access difficulties for many consumers, early discharge from hospital, and increased burden on family and carers. These outcomes increase the likelihood of future unplanned re-admissions.

Demand strategies

3.11 The Department has implemented a number of strategies in an attempt to manage the increasing demand given the level of resources and to overcome some of the issues described above.

3.12 Between 1998 and 2001, the Mental Health Branch provided additional resources to the following areas:

• Crisis Assessment and Treatment Services;

• Residential Rehabilitation;

• Psychiatric Disability Support Services (PDSS)

• Home Based Outreach Support Services; and

• recurrent funding to recognise population growth and an increased awareness of mental health (targeted to some community-based clinical services and acute inpatient services).

3.13 More recently, resources have been directed to the following areas through the Department’s New Directions Plan:

• 30 new acute inpatient beds and the piloting of 30 sub-acute beds Statewide;

• primary mental health care - partly in response to the recognition that more resources are needed for people with common (high prevalence) disorders;

• early intervention - linked to the primary mental health initiatives and targeted to reducing more serious illness;

• dual diagnosis - a Statewide initiative targeting improved service provision to people with a dual diagnosis; and

• high prevalence disorders – funding of “Beyondblue”, the national depression initiative.

3.14 The initiatives described in the Department’s New Directions statement aim to expand the capacity of the current service system. It recognises that demand management and need reduction will be essential to success.

Work force issues

3.15 The delivery of effective mental health services requires an appropriately qualified and experienced mental health work force. AMHS consist of multi-disciplinary teams, including consultant psychiatrists, clinical psychologists, psychiatric nurses, social workers and occupational therapists. This work force diversity helps to ensure that complex consumer needs are adequately met by appropriately trained staff. Commonwealth and State funding plays an important role in supporting the Victorian mental health work force.

3.16 Changes in the composition and distribution of the Victorian mental health work force have been consistent with National Mental Health Strategy directions, and the shift towards community-based care. Between 1993 and 2000, the total number of full-time equivalent staff employed in specialist inpatient services in Victoria decreased by 45 per cent, while staff employed in ambulatory mental health and community-residential services grew by 29 and 68 per cent, respectively⁸. Nationally, the mental health work force has grown just over one per cent on a per capita basis between 1992 and 2000. Victoria’s specialist work force⁹, however, has decreased by 7 per cent (per capita), despite large increases in overall service demand¹⁰.

3.17 The Department’s New Directions statement confirms that there are significant work force issues which place constraints on the mental health system. These include:

• Substantial shortages of nurse, psychiatrist and allied mental health professionals (including psychologists, social workers and occupational therapists), particularly in rural areas;

• Difficulties in recruiting and retaining allied health staff;

• Inadequate mental health nurse training at the university level;

• Relatively unattractive terms and conditions for psychiatrists in the State system compared with the private sector (including lower pay and a more difficult consumer group);

• Significant pay discrepancies between the clinical and non-clinical sectors;

• As a result of these systemic work force issues, AMHSs are making high use of agency staff, and have high sick leave and staff turnover, which increases overall service costs; and

• The Commonwealth also plays a significant role through its funding of university places and its control of psychiatrist provider numbers and Medicare rebates. A number of initiatives taken by the Commonwealth to address other areas of the medical work force could be considered for mental health.

3.18 The Department’s New Directions statement committed the Government to the development of a comprehensive mental health work force plan to be implemented over 5 years. The proposed initiatives seek to:

• attract more people to train and work in mental health;

• better prepare new entrants for work in the mental health services;

• better match availability and skills of existing work force to service needs; and

• encourage skilled and experienced workers to stay longer in the public mental health system.

3.19 We welcome these initiatives which have the potential to develop a sustainable mental health work force. However, the current shortages are having an immediate negative effect on service delivery. Responses from both the State and Commonwealth will be required to address the present work force issues facing mental health services in Victoria.

SERVICE DELIVERY FRAMEWORK

3.20 Guidelines published by the Department describe when and how AMHSs should respond to people during a mental health crisis. The “Client Services Model”¹¹ identifies what should happen after a potential consumer or referring agency makes contact with an AMHS. The model outlines the process of service delivery, which is built around a single point of entry to minimise delay in service response.

3.21 The model’s primary objective is to ensure that consumer’s needs are met effectively and efficiently through the implementation of a core set of processes and functions. Chart 3B shows the key components of the model.

Chart 3B
mental health service delivery framework in victoria

Source: Victorian Auditor-General’s Office, 2002.

3.22 Service activity in response to a referral is grouped into 4 phases. Broadly, these are: Reception, Duty, Intake and Service Delivery. Each phase requires a decision about whether the consumer’s needs are best met through public mental health services or another appropriate service. A description of service access, incorporating Duty and Intake followed by the Service Delivery phases of the Client Services Model is presented below. National Mental Health Standards relevant to each phase, audit findings and conclusions are also discussed.

SERVICE ACCESS (DUTY AND INTAKE)

Introduction

3.23 Duty is the phase during which initial contact is made with a clinical AMHS staff member. Based on an initial screening assessment, the Duty worker determines the most appropriate service response. Departmental guidelines require that all Duty assessments should include an initial assessment of risk and urgency factors. The Duty worker also takes responsibility for making external referrals where appropriate or, alternatively, organising an Intake assessment. The AMHS must record all contacts made with the public on a “screening” form, regardless of whether the contact leads to further assessment or an external referral.

3.24 If the Duty worker considers that public mental health services are appropriate, a more detailed Intake assessment will be provided. The aim of this assessment is to obtain sufficient information to assess the type and level of service response required from the public mental health service. Typically, this will entail an assessment based on face-to-face contact with the person. The Intake assessment should address a number of areas, including: the presenting problem, a psychiatric history, mental state examination, physical assessment, and drug and alcohol use.

3.25 Intake for people in crisis will generally be the responsibility of the area Crisis Assessment and Treatment (CAT) service, particularly if the Duty screening indicates that the referred person may be in the acute stage of a mental disorder, and a response by the community health service is not sufficient to meet the person’s needs.

Service utilisation and consumer characteristics

3.26 The following information summarises key consumer and service utilisation characteristics documented in a random sample of 935 Duty assessment forms at the 6 AMHSs audited:

• Forty per cent of the total sample of 935 referrals contacted the Duty worker for assistance between 9 a.m. and 5 p.m., 26 per cent made initial contact between 5 p.m. and midnight, and 8 per cent contracted services between midnight and 9 a.m. Time of initial contact was not recorded in 26 per cent of cases. Seventy-two per cent of all Duty contacts with the AMHS occurred via telephone, and 28 per cent occurred face-to-face;

• Forty-three per cent of people accessing services were aged between 16 and 34 years, 33 per cent were between 35 and 55 years, and 24 per cent were between 56 and 64 years;

• Referrals to the AMHS came from many sources, however, the most frequent (61 per cent) were referrals by the consumer or their family. Nineteen per cent came from the hospital Emergency Department, 18 per cent came from GPs, and 2 per cent from “other community sources”, including the police and ambulance; and

• Forty per cent of people accessing services were currently registered AMHS consumers, 14 per cent had previously been registered and 21 per cent were new referrals. Due to omissions in AMHS documentation, the remaining 25 per cent were of unknown status.

Presenting problems

3.27 Table 3C illustrates the type and severity of problems, drawn from our sample, presenting to AMHSs. It should be noted that the “presenting problems” are descriptions based on information provided during the initial Duty screening assessment, and should not be interpreted as a final clinical diagnosis. This information provides the basis upon which initial service response decisions are made and can, therefore, influence both the timeliness and appropriateness of response.

Table 3C
problems PRESENTED BY consumers AT
adult Area mental health services
(N = 697)
(PER CENT)

(a) Includes cases with multiple presenting problems.

Source: Victorian Auditor-General’s Office.

3.28 Presenting problems were documented in 96 per cent of the 935 Duty screening assessments examined, however, only 78 per cent of these noted a specific presenting problem or reason for contacting the service. Twenty-two per cent contained requests for information, or ambiguous descriptions, and were excluded from further analysis.

3.29 Self-harm, substance abuse and depression were the 3 most frequently documented presenting problems. Psychotic symptoms were documented in 22 per cent of cases; anxiety, violence and situational crises were present in 26 per cent of new referrals.

3.30 Multiple presenting problems were noted in 23 per cent of cases. The 2 most frequently reported combinations were self-harm and drug or alcohol abuse (9 per cent), and depression and self-harm (7 per cent).

3.31 The large percentage of self-harm referrals (37 per cent) highlights the need for services to record the outcome of risk assessments to ensure a focus on managing the risk of self-harm. The percentage of referrals with substance abuse issues also raises the need for services to establish effective links with drug and alcohol services.

Assessing service access and timeliness of response

3.32 National Mental Health Standards (1996), the Mental Health Act 1986 and relevant departmental guidelines¹² describe the principles for mental health service delivery in Victoria. These documents were referred to when we examined the processes relevant to the Duty and Intake phases:

• Assessing urgency of response required. The AMHS should have a system for prioritising referrals according to risk and urgency. These ratings should be clearly documented in the Duty and Intake records;

• Accessibility and timeliness of service response. The AMHS should be accessible 24 hours a day, 7 days a week, and provide intervention at an early stage of mental disorder (see paras 3.42 to 3.43). This initial, or intake, assessment is used to determine the person’s needs and the most appropriate service required;

• Determining priority for service provision. Services should be provided to people within the defined AMHS target group (see para. 2.8 for definition). The service response should be based primarily on levels of need and disability¹³; and

Standard of documentation. All contacts made with a public mental health service must be documented, regardless of whether or not the contact leads to service delivery.

Assessing the urgency of response required

3.33 Before a service response is initiated, the urgency of the response required must be assessed. National Mental Health Standards require that all services have “a system for prioritising referrals according to risk and urgency”¹⁴. Urgency ratings are made by clinical staff members during the Duty phase, when a referrer makes initial contact with the mental health service. This urgency rating determines the prioritisation of referrals.

3.34 Our examination of 935 Duty assessments revealed that ratings of risk and urgency of response were not recorded in 57 and 53 per cent, respectively, of all Duty assessments. Of those patients who did receive an urgency rating, 83 per cent were rated as “high” to “extreme”, highlighting the serious nature of consumer’s presenting problems.

3.35 The assessment of risk and urgency is a clinical judgement and we have not attempted to audit the veracity of the ratings given. We did, however, observe inconsistencies in the allocation of these ratings and in the responses which followed as a consequence. The nature and timing of service response by the AMHS is dependent on these ratings. AMHS clinicians need clear guidance on the interpretation of these urgency ratings in a range of situations (e.g. where the consumer is an existing client of the service) and training to ensure consistency in the application of those ratings.

3.36 The Department’s New Directions statement commits to the development and piloting of standardised triage assessment for AMHSs. Our audit indicates this action is essential.

Accessibility and timeliness of service response

3.37 Access to AMHS treatment during a psychiatric crisis will typically involve 2 assessments: an initial Duty screening which is often completed by telephone; and an Intake assessment, normally conducted face-to-face by the Crisis Assessment and Treatment (CAT) team. The assessments aim to determine the appropriate service response and may lead to an inpatient admission, treatment in the community, or an external referral to a GP or other professional.

3.38 People experiencing a mental health crisis may also access services by initially contacting a hospital Emergency Department (ED) for assistance. Nineteen per cent of all mental health referrals during the audit originated from a hospital ED – 70 per cent of these referrals were received after-hours.

Presentation to the AMHS

3.39 Analyses of 935 Duty screening assessments were conducted across the 6 AMHSs audited. Our aim was to determine the effectiveness of the Duty screening process in facilitating a timely service response. To achieve this, all 191 Duty presentations rated as “urgent”, which also met the AMHS target group for service provision, were examined to assess the timeliness of the service response¹⁵. People referred to private practitioners for assessment or treatment following initial contact with the AMHS Duty worker were not included in the sample of 191 files audited. Table 3D shows the time (in days) between the rating of a case as “urgent” by the AMHS Duty clinician at the initial point of contact with the service and a face-to-face assessment by an AMHS clinician.

Table 3d
time in days BETWEEN AMHS RATING A CASE as “urgent” AND
PROVIDING A FACE-TO-FACE ASSESSMENT
(N = 191)
(PER CENT)

(a) Face-to-face contact with an AMHS clinical staff member.

(b) Includes Goulburn Valley, Gippsland and Barwon.

(c) Includes Dandenong, Mid-West and Inner Urban East.

Source: Victorian Auditor-General’s Office 2002.

3.40 Assuming our sample of 191 case files had been correctly assessed as “urgent” by AMHS clinicians, the data in the above table shows that 65 per cent of initial service contacts rated as “urgent” did not receive a face-to-face assessment by an AMHS clinical staff member within 24 hours. Twenty-five per cent of urgent cases did not receive an initial face-to-face assessment by an AMHS clinician for 7 or more days.

3.41 Overall, rural services were faster to respond to urgent referrals than metropolitan services. Differences between individual services and response times during the day versus overnight could not be reported due to incomplete AMHS data. However, the audit found that demand for services was typically high during the evening and overnight period, partly because other community-based services and private psychiatrists are generally not available after-hours. Reliance by AMHS on one Duty worker overnight also meant that for some referrals there was a delayed response if an assessment was in progress.

3.42 There is debate regarding the appropriate standard against which timeliness and appropriateness of service response during a psychiatric crisis should be measured. The relevant standards and guidelines are not universally accepted and there are differences in interpretation between the Department, AMHSs and mental health practitioners. AMHSs are also at varying stages in adopting the national standards. Accreditation against the national standards will commence in June 2003.

3.43 Professional advice received from the Victorian Branch of the Royal Australian and New Zealand College of Psychiatry is that clinical assessments of urgent referrals need to occur within one hour (allowing for travelling time) and, aside from exceptional circumstances, these assessments should be conducted face-to-face. Professor Harvey Whiteford, Chair of the 1997 National Mental Health Working Group for mental health standards, advised that:

“For presentations rated as urgent by an AMHS clinical staff member at the initial point of contact with the service, a clinically appropriate intervention should occur within 24 hours. This clinical intervention should, in most instances, be a face-to-face assessment by a clinical staff member or another appropriate clinician (e.g. general practitioner) determined by the AMHS. The intervention could commence as a telephone intervention where this is deemed by the AMHS to be clinically appropriate and sufficient to respond to the immediate needs of the consumer.

Intake assessments

3.44 Intake assessments follow the initial screening assessment by the AMHS Duty worker and aim to determine the type of service response required. Intake assessments for consumers who received treatment from an AMHS were examined at the 6 AMHSs audited during the file review. The results indicated that 22 per cent of the 935 files examined did not contain an intake assessment. Of the 729 files that did contain an assessment, 87 per cent were incomplete; that is, one or more of the criteria noted in Table 3E were not addressed in the Intake assessment. Where Duty and Intake occurred concurrently, we rated the criteria as met if there was evidence in either the Duty or Intake assessment forms.

Table 3E
intake assessments, file audit findings
(N = 729)
(PER CENT)

Source: Victorian Auditor-General’s Office 2002.

3.45 Evidence of referrals to appropriate services for consumers referred externally were documented in only 24 per cent of cases. Examples of good practice were noted at Barwon and Goulburn AMHS, where Intake information was appropriately documented, stored securely and placed in an accessible file to allow effective review of those who do not enter the system or who re-present to services at a later date.

Presentations to Emergency Departments

3.46 All presentations to Emergency Departments (EDs) are initially assessed by the ED triage worker. If the presentation indicates a mental health crisis, the AMHS clinician will be contacted to organise an appropriate mental health service response. During a psychiatric crisis, this will normally involve the Crisis Assessment and Treatment (CAT) team.

3.47 One hundred and seventy-one (18 per cent) of all mental health referrals during the audit originated from a hospital ED. Analysis of ED referral data shows consumers presenting with serious mental health problems, including risk of deliberate self-harm, substance abuse, depression and psychotic symptoms. Audit findings from the 6 AMHSs indicated that:

• 68 per cent of all referrals from an ED were rated as high to extreme risk of self-harm;

• high risk of self-harm was reported in 47 per cent of presentations;

• drug and/or alcohol problems were documented in 48 per cent of cases;

• aggressive behaviour was also common, reported in 28 per cent of presentations; and

• 25 per cent of all ED presentations with a mental health component came via the police.

Emergency Departments are a critical access point
to after-hours mental health services.

3.48 A number of problems with current ED arrangements for assessing and treating people with mental health problems were identified during the audit. These included:

• Based on our limited observations during the audit, consumers presenting to EDs with serious mental health problems often experience lengthy waiting periods. Waiting for an inpatient bed or a CAT service were responsible for delays on several occasions;

• Often a slow response to people in psychiatric crisis, particularly overnight. Data provided by the Royal Melbourne Hospital ED indicates that average waiting times in the ED for psychiatric inpatient beds ranged from 5 to 20 hours in April 2002¹⁶;

• Inadequate physical infrastructure for psychiatric patients. In most of the 6 EDs, private, quiet areas for the assessment of patients and carers were not available (St Vincent’s hospital was an exception);

• Uneven use by EDs of the Australia Triage Scale for the assessment of young people with evidence of deliberate self-harm, rather than the routine use recommended by the Australasian College of Emergency Medicine¹⁷; and

• No routine collection and analysis on a Statewide basis of information concerning the number and type of mental health cases presenting to ED. This prevents services from appropriately monitoring trends in service utilisation, and adjusting resource allocation accordingly. The Department, as part of its demand management strategy, proposes collection and analysis of such data.

Consumer and carer views on access and timeliness

3.49 Seventy-four per cent of consumers interviewed about their experiences reported that the service response was “too slow” and “not treated with sufficient urgency”¹⁸. Consumers reported that in many cases, the delay led to an escalation of the crisis and involvement with police or admission to hospital.

3.50 Carers reported feeling “completely helpless” during a psychiatric crisis, noting that services were “extremely reluctant” to offer immediate assistance unless the person being referred was acutely psychotic or suicidal. Carers noted a tendency for services to deflect responsibility to the carer or family member in circumstances where an urgent response was required, placing an immense strain on family members. This was particularly common when assistance was sought from services after-hours (that is, between 5 p.m. and 9 a.m.).

Determining priority for service provision

3.51 The Government’s objective is to provide public mental health services to a broad target group. The Department’s Framework for Service Delivery (1994) indicates that the target group for service provision includes people with “serious mental illness”, defined as consumers suffering from “… functional psychoses, both acute and persistent, severe mood or eating disorders, or with severe anxiety disorders, as well as those who present with situational crises which may lead to self-harm or inappropriate behaviour directed towards others. People with a severe personality disorder whose behaviour places themselves or others at risk of harm are included in the target group”. Importantly, national standards and departmental guidelines note that service access should be based primarily on consumer need and associated levels of disability.

3.52 The prevalence of “common” mental disorders, including depression and anxiety in the Australian community, is approximately 5 to 10 times higher than the prevalence of psychotic disorders. Moreover, associated levels of “disability” may be equally as high (or in some cases higher) in presentations of severe depression and anxiety. The Victorian Burden of Disease Study (1999) and the national surveys of Mental Health and Well-Being (1997-1998) have been used to estimate the “disability burden” of mental disorders in terms of years lost due to disability (YLD). The results indicate that the disability burden of mood, anxiety and personality disorders, which, when serious, fall within the AMHS target group for service provision, is significantly higher than the total disability burden associated with psychotic disorders. These differences are illustrated in Chart 3F.

CHART 3F
estimated DISABILITY burden (YLD)
by diagnosis, Australia, 1997 TO 1998

Source: Gavin Andrews et al, World Health Organisation Collaborating Centre for Evidence for Health Policy, UNSW at St Vincent’s Hospital, Sydney. Paper presented at the Mental Health Services Conference, Sydney, 21 August 2002.

3.53 The Second National Mental Health Plan (1998) notes that an unforseen consequence of the first Plan’s (undefined) use of the term “serious mental illness” was that it lead to variable local interpretations of the term and for some public services to “erroneously equate severity with diagnosis rather than level of need and disability”. In practice, this has generally lead to psychotic disorders gaining access ahead of the more common mental disorders. The Second Plan (1998, p. 10) goes on to note that “... it is therefore important to acknowledge the problems created by the overly narrow interpretation of the original policy which can result in consumers not gaining access to services …”

3.54 The audit sought to assess whether AMHSs were providing services to consumers based upon their level of need and disability (in accordance with national standards and departmental guidelines), or according to the consumers’ diagnosis. The audit examined data relating to the consumer’s presenting problem since this is the only information available at the point of duty/intake when the decision is being made to provide the consumer with a service or refer them elsewhere.

3.55 Data was available for 697 presenting problems, as shown in Chart 3G. These data show that persons with psychotic symptoms are more likely to receive a service from AMHSs. Consumers with other presenting problems including self-harm, depression, situational crises, anxiety, eating and personality disorders (all of which are included in the AMHS target group for service provision) were more likely to have their file marked “No further action required” or to be referred to a non-AMHS service provider.

Chart 3G
AMHS service response for ALL presentING PROBLEMS
(N = 697)
(PER CENT)

(a) Presenting problems include personality disorders, eating disorders, adjustment disorders and organic disorders.

Source: Victorian Auditor-General’s Office, 2002.

3.56 The severity of the presenting problems in Chart 3G will vary and some may reasonably be referred elsewhere to be dealt with by service providers other than AMHSs. We therefore examined a subset of the files for consumers who had been classified as “urgent” and compared the provision of services on the basis that people classified as “urgent” should have a similar level of need¹⁹. The relationship between presenting problem and service response as shown in Chart 3H suggests that the majority of consumers rated as urgent received an AMHS service response.

CHART 3H
RELATIONSHIP BETWEEN PRESENTING PROBLEM
AND AMHS SERVICE RESPONSE TO “URGENT” REFERRALS
(n = 320)
(per cent)

(a) Presenting problems include personality disorders, eating disorders, adjustment disorders and organic disorders.

Source: Victorian Auditor-General’s Office, 2002.

3.57 Table 3I shows the diagnoses of psychiatric patients registered in 2001, obtained during the file audit, across the 6 AMHS audited. The data indicates that people with psychotic disorders (including schizophrenia) constitute the largest diagnostic group of patients, while mood disorders and all other mental disorders account for 34 and 22 per cent of all diagnoses, respectively.

Table 3I
principal diagnoses of people registered
with area mental health services in victoria (A)
(N = 580)

(a) Diagnoses are taken from MH1 registrations forms for consumers registered in 2001.

(b) Includes eating, somatoform and dissociative disorders, and other mental disorders due to brain damage.

Source: Victorian Auditor-General’s Office, 2002.

3.58 During interviews with consumers and carers, a common source of complaint was that consumers and carers believed that AMHS provided services based on a person’s diagnosis as opposed to their level of need and disability. AMHSs noted the difficulties they face in providing services to a broad target group, in an environment of limited resources. The data examined by this audit has not been able to clarify whether or not there is a differing service response for consumers with similar levels of disability and need, but different diagnoses.

Standard of documentation

3.59 Documentation of Duty referrals is important for quality assurance, service efficiency and monitoring purposes. We found that there was considerable variation in the comprehensiveness of the 935 Duty records examined, with significant omissions noted across all services, including basic demographic information, such as date of birth, address and gender not recorded. Time of call to the Duty worker was not recorded in 26 per cent of cases, impeding the capacity of services to monitor their response times in hours.

3.60 The documentation of Duty processes at St Vincent’s Mental Health Service was particularly concerning. There was no system for collating and analysing data on referral sources; Duty notes did not allow recording of risk levels; new consumers could not be distinguished from existing service users; and entries were recorded on separate Word documents, making data analysis exceptionally difficult.

3.61 By contrast, Barwon, Gippsland and Goulburn Valley AMHSs all used standardised psychiatric Duty assessment forms, which included all relevant fields, prompting the Duty worker to collect important information, including both risk and urgency ratings. Similarly, Goulburn Valley AMHS had developed a comprehensive local Duty database, enabling easy access and analysis of all contact details.

3.62 While the majority of Duty assessments audited contained clear, legible descriptions of the presenting problems, we noted across all 6 services a number of vague descriptions, and in some services stigmatising or unprofessional descriptions, such as “he’s really sick”, “he’s going bananas” and “she’s lost the plot”. Moreover, the rationale for the Duty worker’s decision to accept or refer a consumer externally was not consistently documented.

3.63 This issue has been recognised by the Department in its New Direction plan and it is proposed to better clarify roles and responsibilities, and target groups between services.

Conclusions

3.64 People accessing public adult mental health services present with a range of complex problems, and a high degree of need and distress. They are frequently at risk of suicide or self-harm, with substance abuse, depression and psychotic symptoms present in a majority of cases. The severe nature of these presenting problems highlights the importance of a timely, appropriate service response.

3.65 In our sample review, ratings of urgency and risk of self-harm were absent in 53 and 57 per cent, respectively, of all Duty assessment forms. We observed disparate ratings of similar presenting problems within services. In the absence of documented criteria or guidelines, ratings of urgency and risk were based on the personal judgement of individual clinicians. This makes it difficult for services to consistently prioritise new referrals according to urgency and risk, as required under the National Mental Health Plan.

3.66 Our sample review found that 65 per cent of referrals rated as “urgent” by the AMHS Duty clinician at the initial point of contact with the service, did not receive a face-to-face assessment by an AMHS clinical staff member within 24 hours.

3.67 Nineteen per cent of all presentations in the audit sample came through the hospital ED. Audit findings indicate that psychiatric patients often experience lengthy delays in the ED. Audit observations indicate that the physical infrastructure in most EDs was not adequate for the assessment and management of psychiatric patients.

3.68 During interviews with consumers and carers, a common source of complaint was that consumers and carers believed that AMHS provided services based on a person’s diagnosis as opposed to their level of need and disability. AMHSs noted the difficulties they face in providing services to a broad target group, in an environment of limited resources. The data examined by this audit has not been able to clarify whether or not there is a differing service response for consumers with similar levels of disability and need, but different diagnoses.

3.69 While all 6 AMHSs audited had systems in place to enable collection of service access data, there were significant omissions in the data being recorded by clinical staff. AMHS staff are not currently completing the majority of Intake assessments appropriately. This increases the risk of the psychiatric assessment being compromised, and may lead to an inappropriate service response. This situation is adversely affecting the extent to which services can monitor and evaluate service access and entry information, which is required under the national standards.

Recommendations

3.70 We recommend that the Department work with AMHSs to:

• Clarify definitions and interpretations of the standards for urgency, timeliness and nature of initial service response in line with the national approach, and ensure that there is sufficient guidance and training for AMHS staff to implement the agreed standards consistently;

• Review current arrangements for the assessment and treatment of psychiatric patients in EDs with the aim of improving response times and treatment to people in psychiatric crisis, including:

• the respective roles and responsibilities of ED clinical staff and mental health staff during a psychiatric crisis; and

• physical infrastructure in EDs including areas designed for the assessment, management and restraint of psychiatric patients;

• Monitor and report on service provision within AMHS against agreed standards to enable appropriate responses to be made where standards are not achieved; and

• Improve Duty documentation procedures at AMHSs to enable appropriate service monitoring and accountability. Specific areas for improvement include ratings of urgency and risk of harm to self and others, and key intake criteria and completion of key assessments.

SERVICE DELIVERY:
PSYCHIATRIC HOSPITALISATION

3.71 Hospitalisation aims to provide assessment and acute management of consumers in psychiatric crisis until they can reasonably be managed in a less restrictive setting. Inpatient care is particularly important for consumers during the acute phase of a crisis, as it enables a level of specialised, 24-hour care which is generally not available in the community.

Hospitalisation provides assessment and support for people during a mental health crisis.

3.72 The following principles, taken from the National Mental Health Standards (1996) which have been accepted by the Department, are relevant to psychiatric hospitalisation and have been adapted as audit criteria:

• The AMHS ensures access to high quality psychiatric inpatient services for consumers who meet the AMHS target group for service provision. Admission to psychiatric inpatient services should be based on consumer need, and the level of urgency and risk associated with the presentation, with every attempt made to promote voluntary admission for the consumer; and

• A discharge plan should be developed in consultation with the consumer on admission to the facility. The plan should describe treatment and discharge strategies as described in departmental guidelines²⁰.

Access to inpatient services

3.73 A recent Statewide review of adult acute psychiatric inpatient services reported that it is becoming increasingly difficult for consumers to gain access to acute inpatient beds in some areas. Victoria has emphasised community-based services providing a higher proportion of its services and beds in community settings than other States. The overall number of designated acute psychiatric inpatient beds in Victoria has remained relatively constant since 1996, despite a 20 per cent increase in overall service demand. Victoria now has 21.8 acute beds per 100 000 adults; 2.6 beds below the national average²¹.

3.74 Chart 3J illustrates recent changes in demand for inpatient beds (measured by the number of admissions), and corresponding changes in the average length of stay.

CHART 3J
Changes in adult acute inpatient service
demand and average length of stay

Source: Department of Human Services, 2002.

3.75 While demand has increased just under 10 per cent per year between 1995 and 2000, the average length of stay (LOS) has decreased from 16 days to 12 days and the number of per capita beds available has remained relatively constant. The Department advised that one and 2 day admissions have increased in recent years, contributing to the reduction in average LOS. The trend towards shorter inpatient admissions appeared to be reversed in 2001, when average LOS was estimated by the Department to be around 14 days. Average LOS data for 2002 could not be provided by the Department within our timeframe due to data extraction difficulties with the new Statewide database, “RAPID”²².

3.76 Changes in average LOS alone do not indicate a shortfall in the supply of inpatient services, since there have also been ongoing changes in treatment approaches. However, audit review of files indicate that it is becoming increasingly difficult for people to gain access to acute inpatient services and a very high level of symptom severity is necessary to gain access to beds. Within this context, reductions in average LOS appear to reflect, at least to some extent, a service response to managing increasing demand and a constant supply of acute inpatient beds.

3.77 Increasing demand for psychiatric beds has also resulted from a 23 per cent increase in the total number of involuntary admissions from July 1995 to September 2000²³. (Note: data concerning more recent trends in involuntary status could not be provided by the Department due to data extraction problems with the new Statewide database, “RAPID”). The inpatient bed shortage has been recognised by the Government in its New Directions statement, and an additional 30 acute beds and 30 sub-acute (or “step-down”) beds are to be funded.

Discharge from inpatient services

3.78 For most consumers, ongoing support will be necessary after discharge from an inpatient service. This may include case management in the community or referral to an external agency or private practitioner. Discharge planning helps to ensure that consumers receive appropriate ongoing treatment in the community. This process maximises the opportunity for recovery and may reduce the likelihood of future unplanned re-admissions. The AMHS case manager and inpatient staff are jointly responsible for developing the discharge plan, and ensuring that consumers are linked into, and followed-up by, appropriate community-based services²⁴.

3.79 Departmental guidelines²⁵ and national standards describe what an appropriate discharge plan should include. During the clinical file audit, discharge plans for consumers who received inpatient treatment in the previous 12 months were reviewed against these guidelines. Discharge plans were present for 78 per cent of consumers in the audit sample. However, all these plans were incomplete (i.e. one or more key standards were not addressed in the plan). The results of our assessment against the guidelines are shown in Table 3K.

Table 3K
discharge plans, results of clinical file audit
(N = 315)
(PER CENT)

Source: Victorian Auditor General’s Office, 2002.

3.80 Key findings from the file audit include:

• Eighty-nine per cent of 315 previously hospitalised consumers reported that they were discharged while still acutely unwell, with a high level of need for ongoing support;

• Thirty per cent of all discharge plans reviewed included no evidence that consumers had been linked into appropriate community-based services for ongoing treatment following inpatient discharge. Risk of suicide among mental health consumers reaches a peak during the weeks immediately following inpatient treatment, highlighting the importance of appropriate discharge planning and ongoing support;

• Evidence that carers were consulted in the formulation of a discharge plan and consulted regarding impending discharge arrangements were absent in the majority of plans examined. Carers interviewed during the audit reported that patients were frequently discharged without their knowledge or involvement, placing considerable burden on family/carer support; and

• Information regarding early warning signs of relapse, re-accessing services, relapse prevention or community follow-up plans were rarely recorded on file as having been provided to consumers or carers.

3.81 These findings highlight significant problems with current discharge practices from psychiatric inpatient facilities in Victoria. Poor discharge planning has the potential to compromise ongoing patient care, increase the burden on families and carers, and may result in unplanned re-admission to hospital.

Conclusions

3.82 Audit findings, Statewide data and the recent review of psychiatric inpatient facilities commissioned by the Department indicate that access to psychiatric inpatient beds for eligible consumers is becoming increasingly difficult.

3.83 The audit found that consumers are frequently discharged from inpatient facilities without being connected into appropriate community-based services for ongoing care. This situation increases the likelihood of future unplanned re-admissions to hospital.

3.84 Significant gaps in the completion of key discharge criteria were noted during the file audit, including limited evidence of consultation with consumers and carers, indicating that current discharge practices are not consistent with national standards and guidelines.

Recommendation

3.85 We recommend that the Department and AMHSs significantly improve current discharge practices. Particular attention should be given to post-discharge arrangements with ongoing community-based services, and consumer and carer collaboration in discharge planning.

Ongoing community-based treatment is critical for prevention of mental health crises.

SERVICE DELIVERY:
COMMUNITY-BASED TREATMENT

3.86 Service delivery at each AMHS is achieved through case management of individual consumers. The case manager’s role is to co-ordinate the provision of care to meet the consumer’s individual psychiatric and social needs. This may involve the direct provision of clinical treatment by the case manager.

3.87 Comprehensive assessments and the development of individual service plans (ISPs) form the basis of effective case management and consumer care. Discharge planning following inpatient admission, and case closure after community treatment are the responsibility of the case manager. Audit findings relevant to each of these core service delivery elements are described in this section. Relevant national standards and departmental guidelines which have been adapted as audit criteria include:

• All registered AMHS consumers should be assigned a case manager upon entry to the service. The case manager’s role is to develop and implement appropriate treatment plans, and to co-ordinate care to meet individual consumer needs;

• A comprehensive needs assessment should be completed by each consumer’s case manager. The assessment should address key areas of need and functioning described in departmental guidelines;

• There should be documented evidence of an individual ISP in the clinical file of each consumer registered with a public mental health service. The ISP should address treatment goals and strategies, and should be developed in collaboration with the consumer and (where available) the carer;

• ISPs should be formally reviewed at least once every 6 months. Evidence of the review should appear in the clinical file;

• The AMHS case manager should ensure that the consumer and family members (or carers) receive appropriate information about the nature of the mental disorder and relevant treatment options - a process referred to as “psycho-education”;

• Consumers should have access to a range of treatments, including psychological and psychosocial interventions²⁶;

• Treatment outcome measures should routinely be used and recorded by the service;

• A case closure plan should be formulated for each consumer prior to exiting the service. The closure plan should address key criteria described in departmental documents²⁷; and

• The AMHS and other relevant services should develop and maintain appropriate links with other service providers to ensure specialised co-ordinated care and promote community integration for people with mental disorders²⁸.

Case management

3.88 Effective case management is central to mental health service delivery in Victoria. The Department’s 1994 Framework for Service Delivery requires that every consumer registered with a mental health service must have a designated case manager who is responsible for the co-ordination of services to meet their individual needs. The core functions of case management include the assessment of consumer needs, treatment planning and co-ordination, symptom monitoring and review, and discharge or case closure planning.

3.89 Our audit of 935 clinical files indicated that 97 per cent of all registered AMHS consumers had a case manager. However, allocation of case managers to individual consumers did not always occur on the day the consumer was registered with the AMHS, as required by national standards. In the audit sample, 67 per cent were allocated on the same day, while the remaining 33 per cent were allocated 2 to 7 days after the consumer registration date, indicating that some consumers had to wait several days before being assigned a case manager. The Department advises that all consumers should have a contact person until a case manager is assigned.

3.90 Case management guidelines indicate that it is preferable for consumers to work with the same case manager while they are registered with the service. This helps to maximise “continuity of care” for the consumer, while also encouraging a therapeutic alliance between the case manager and the consumer. Departmental documentation was insufficient to enable this requirement to be tested, however, 62 per cent of all consumers interviewed during the audit indicated that high case manager turnover and poor continuity of care during AMHS treatment were a “serious concern”.

3.91 Eighty-seven consumers and 85 carers interviewed during the audit reported specific concerns with the implementation of the case management model, including:

• the “accessibility” of case managers, particularly during critical stages of service delivery or when a relapse occurred;

• poor communication with carers about assessments, treatment planning, discharge and case closure; and

• the apparent reluctance or inability of case managers to assertively follow-up consumers in the community, particularly treatment of non-compliant or “difficult” consumers.

Comprehensive assessments

3.92 When a consumer is accepted for treatment, a comprehensive assessment addressing key areas of need and functioning must be completed and documented in the clinical file. The assessment is crucial in the determination of the level of response and the requirement for external agency involvement. Comprehensive assessments also form the basis of the consumer’s ISP.

3.93 In total, 239 comprehensive assessments were examined for registered consumers who received treatment with an AMHS. Each assessment was examined to determine whether 6 key criteria had been addressed, consistent with departmental guidelines²⁹. The audit found that 96 per cent of the 239 comprehensive assessments examined were missing one or more of the 6 key criteria. Results are shown in Table 3L.

Table 3L
comprehensive assessments: file audit results
(N = 239)
(PER CENT)

(a) While the majority of assessments contained a mental state examination, auditors found that the majority were not completed adequately.

(b) Barwon AMHS was the only service audited which routinely documented psychosocial assessments as required by departmental guidelines.

Source: Victorian Auditor-General’s Office, 2002.

3.94 These results highlight a focus on clinical examinations and indicate significant gaps in the documentation of other important assessment criteria used to formulate ISPs. The absence of this information in clinical files raises concern regarding the comprehensiveness of the assessments used to formulate treatment planning and service delivery.

Individual service planning

3.95 Individual service plans (ISPs) form the basis of community-based psychiatric treatment. Every consumer registered with a public mental health service who receives community-based treatment from an AMHS must have an ISP. The ISP should be developed in collaboration with the consumer, be reviewed at least every 6 months, and address key areas of need and functioning³⁰.

3.96 A review of 935 clinical files found that 31 per cent of 583 consumers treated in the community did not receive either an ISP or an inpatient management plan. Furthermore, none of the 402 ISP examined addressed all of the criteria as recommended by Departments’ clinical guidelines. The results are shown in Table 3M.

Table 3M
individual service plans: file audit results
(N = 402)
(PER CENT)

Source: Victorian Auditor-General’s Office, 2002.

3.97 Interviews with consumers reinforced the file audit findings. Thirty-one per cent of consumers interviewed stated that an ISP had not been developed for them. Only 25 per cent of these consumers recalled any involvement in ISP development. The general theme which emerged from the interviews was that consumers and carers felt excluded from this critical process³¹.

ISP reviews

3.98 ISPs must be reviewed at least once every 6 months. The review aims to ensure that the progress of treatment goals is evaluated and treatment strategies are updated to ensure they remain relevant to the consumer’s changing needs. The ISP review should be a collaborative effort between the consumer and their case manager. With the consumer’s consent, family and/or carer(s) should be involved in this process.

3.99 File audit results indicated that only 24 per cent of the available 402 files containing an ISP showed evidence of having been reviewed within the required 6 month period. Modification of ISP’s goals rarely occurred before the scheduled 6 monthly review. In cases where a review was present, less than 5 per cent contained evidence of consumer collaboration. Carer involvement was cited in less than one per cent. Illegible writing, and the absence of signatures and the designation of staff members were also common.

Access to appropriate information

3.100 Patients and carers benefit greatly from receiving appropriate information about the nature, causes and treatment of mental disorders. “Psycho-education” is generally considered an integral part of the treatment and recovery process³² and is emphasised in the national standards. The responsibility for providing psycho-education typically rests with the AMHS case manager.

3.101 Evidence of consumer and carer psycho-education was absent in 84 and 98 per cent, respectively, of consumer files audited. Audit observations and interviews with consumers and carers confirmed these file audit results. While it is possible that these results may reflect poor documentation practices, 68 per cent of consumers interviewed stated that their case manager did not provide any form of education about their mental disorder, nor were they referred to an alternative agency to receive this service. Similarly, carers often complained (during carer focus groups) about the lack of information and education they received from AMHSs regarding mental disorder generally, and treatment and prognosis.

Treatment options

3.102 National standards require that public mental health service consumers should have access to a range of appropriate medical and psychosocial treatments. Research indicates that medication and psychosocial interventions together are generally more effective in the treatment of serious mental disorders than medication alone³³. In order to maximise the effectiveness of therapeutic intervention, and to reduce the likelihood of unplanned re-admission, it is important the consumers have access to appropriate treatments.

3.103 We found that psychosocial (or non-drug) interventions were documented in only 4 per cent of cases. Many consumers interviewed were concerned by the “over use” of medication and the “unavailability” of psychological interventions such as cognitive behaviour therapy. Similarly, carers generally believed that “treatment” equated to medical intervention in the public system. It is noted, however, that psychosocial intervention may be provided to some consumers with severe and disabling long-term mental disorders through Psychiatric Disability Support Services (PDSS). These services were not within the scope of this audit.

Outcome measures

3.104 Measuring the effectiveness of clinical care is an important service monitoring process. The inclusion of outcome measures in routine clinical practice enables examination of which treatments work best for different consumers, so that treatment effectiveness can be maximised.

3.105 For this reason, national standards note that all mental health services should “routinely monitor health outcomes for individuals”³⁴. The Department also recommends that all AMHSs implement the Health of the Nation Outcome Scale (HoNOS) for the purpose of measuring treatment outcomes. Outcome measures should be completed by the case manager and documented in the clinical file.

3.106 File audit results indicated that 82 per cent of all registered consumers’ files did not indicate that a HoNOS had been prepared before or after treatment. There was minimal evidence that alternative outcome measures were being used by services. Barwon AMHS was an exception to this finding; 55 per cent of registered consumer files contained a HoNOS.

3.107 We note that the Departments New Directions statement commits the Department to providing assistance to all clinical services in 2002-03 to enable them to implement routine outcome measurement. Our audit results confirm the need for such action.

Case closure

3.108 Case closure occurs when a consumer no longer requires public mental health services. Formal case closure requires the completion of an appropriate service exit process, which should address a number of key criteria as set out in the departmental guidelines³⁵. The guidelines note that “the decision to close a case should be made together with the consumer and significant people in their life”, and that the case closure plan should be developed prior to case closure, and include relapse prevention strategies and information about how to re-access the system.

Case closure plans should include relapse prevention
strategies and information about how to re-access the system.

3.109 Our file audit found that 36 per cent of all consumers who had received community treatment and exited the system did not have a documented case closure plan on their file. File audit results examining case closure plans are shown in Table 3N.

Table 3N
CASE CLOSURES: file audit results
(N = 373)
(PER CENT)

Source: Victorian Auditor-General’s Office, 2002.

3.110 Consumers and carers expressed concern regarding the case closure process, including a general lack of involvement in case closure planning. The results indicate significant omissions regarding case closure planning and documentation.

Service linkages

3.111 Mental health consumers typically present with multiple problems requiring the co-ordination of different services. It has been estimated that up to 70 per cent of adults with a psychosis have a drug or alcohol abuse problem³⁶. Similarly, rates of homelessness, and physical and intellectual disability are higher among people with a mental disorder, compared with the general population³⁷.

3.112 The number of consumers presenting to mental health services with complex problems is increasing. As the complexity of consumer need grows, effective collaboration and communication between mental health and other service sectors becomes increasingly important.

3.113 Service providers have not always been clear about their respective roles and responsibilities in managing consumers with multiple service needs, including drug and alcohol problems. Some consumers and carers interviewed during the audit reported being pushed between services and, consequently, failing to receive the services they required. In our consultations and those reported in the Department’s New Directions statement, there is a recognised need for protocols to encourage collaboration and effective linkages between services. Protocols between mental health services, hospital Emergency Departments and disability support services require improvement, and successful pilot programs require further expansion.

3.114 File audit results indicated that 30 per cent of hospital discharge plans reviewed included no evidence that consumers had been linked into appropriate community-based services for ongoing treatment following inpatient admission. Similarly, 48 per cent of all case closure plans (or service exit plans) reviewed indicated no evidence that consumers had been linked into appropriate services for ongoing care in the community.

3.115 Mental health service staff report that communication has improved in some regions as a result of recent service initiatives (see Part 2 of this report). They described improvements in service efficiency (more appropriate referrals, sharing of skills/knowledge) and service effectiveness (improvements in the quality and continuity of care). Frameworks for collaborative arrangements between Mental Health and Drug and Alcohol services, the police and ambulance, and primary care providers (GPs) were generally praised. While the Department advises that the Dual-Diagnosis program is available Statewide for adults, significant problems remain in many regions, with consumers reporting inadequate co-ordination of services.

Conclusions

3.116 Demand for mental health services is increasing. There is evidence of substantial unmet need for both acute inpatient and community-based mental health services in Victoria.

3.117 The present under-supply of community-based mental health services is increasing pressure on acute inpatient services, resulting in longer response times, access “rationing”, high staff workloads, reduced quality of patient care and increased patient “throughput”. These outcomes may lead to additional unplanned inpatient re-admissions.

3.118 Audit findings highlight significant gaps in the completion of key service delivery processes, including comprehensive assessments, ISPs and case closure plans. The absence of this information, together with consumer and carer feedback, suggests that service delivery is being compromised in these areas. Interviews with consumers and carers, and file audit results indicate that consumers of public mental health services are not routinely receiving psycho-educational services from the public mental health system or being referred to the private system for these services as recommended under national standards.

3.119 Recent departmental initiatives have led to improvements in the joint management of consumers with complex needs. However, significant gaps still exist, resulting in many of these consumers failing to receive timely and appropriate in services.

Recommendations

3.120 We recommend that:

• The Department of implement a comprehensive demand management strategy;

• AMHSs Services ensure that all components of service delivery are completed and documented, including completion of comprehensive assessments, individual service plans, and Case closure planning conforming to national standards; and

• The Department continue to develop new service interface initiatives and expand existing initiatives which have proven successful. Linkages with primary care providers, drug and alcohol services, and housing services are particularly important in this regard.

RESPONSE provided by Department of Human Services

In relation to the urgency rating, DHS makes the following comment:

An urgency rating indicates the necessity for some immediate action to be taken. This could take a range of forms. The first step is generally the collection of information to help clarify the nature of the problem. Such information will frequently alter the original rating allowing for revised clinical judgement. This may, however, not be documented on the file.

The Department of Human Services acknowledges that more training should be provided to services so that urgency ratings are more consistent and that any action taken, which changes the rating is documented on the file.

Access to Beds

There are pressures on acute inpatient beds for a wide range of reasons, some at the front end of the service system and some at the extended care, high support end. The opening of 30 additional acute beds, and 30 sub-acute beds funded in the 2002-03 budget will assist in addressing this identified problem.

It should also be noted that 25 acute beds will be opened at Berwick in 2004.

As acknowledged in the New Directions for Victoria’s Mental Health Services it is important to build on the strengths of the current system by developing an appropriate mix and level of services and implementing new and innovative approaches to consumer needs.

In the New Directions for Victoria’s Mental Health Services Work force strategy was identified as one of the prerequisites to achieving the other key directions. Work force strategy development is underway.

Since 1999, there has been an increase in the number of direct care staff employed in Victorian mental health services, with services reporting an overall increase of more than 230 staff between 1999–2000 and 2000–01.

In addition, a commitment was made through the Psychiatric Services Enterprise Bargaining Agreement in 2000–01 to fund a wide range of nursing initiatives, including 116 education, training and supervisory positions and an additional 130 nurse positions over a three-year period.

These initiatives included a significant increase in nurse training and development positions at Grade 4, 5 and 6 or 7 level, representing the first formal recognition of the need for training and development positions in mental health since mainstreaming occurred in the 1990s. Staff in these positions are supporting improvements in clinical practice and skill development and will assist nurses working in an increasing complex environment.

A specific localised mental health nurse recruitment and retention campaign has been developed, following on from the specialist nurse recruitment and retention campaign.

Audit Findings

See Department of Human Services comments at the end of the Executive Summary.

If the percentage of the population with a serious mental illness is closer to 2 per cent or 95 000 then the Mental Health Branch of DHS estimated that more than 100 per cent of the potential population of people with a serious mental illness receive services. If you assume 2.5 per cent of the population have a serious mental illness then almost all of the potential population with a serious mental illness are receiving a service. The National Mental Health report 2000 says that serious mental illness is between 2 and 3 per cent of the population.

Audit acknowledges that Victoria provides a higher proportion of services and beds in community settings than other states but then concludes that this is inadequate. Victoria has 22.9 inpatient beds per 100 000 and 20.0 24-hour residential beds per 100 000 bringing the beds to a total of 42.9 per 100 000. This includes aged, child and adolescent and adult beds.

The Department Inpatient Services Review 2000 found that the number of beds across the state appeared to be in line with other states but identified an inequitable distribution of inpatient beds across the state³⁸.

Since that review there has been considerable growth in service demand, and in 2002-03, 30 extra sub-acute and 30 acute beds plus more home-based treatment were funded. 25 Adult beds are to be developed at Berwick by 2004. A capital plan is being developed. The capital plan will form part of an asset investment model for all health facilities across Victoria including PDSS capital assets, supported accommodation issues and residential options for consumers, including those with a dual diagnosis.

DHS are putting in place systems to be able to collect data on unplanned readmissions and response times. This information is not currently available.

The clinical guidelines for Individual Service Plans (ISP) do not require all the criteria to be addressed. The criteria are not and should not be considered mandatory. For example evidence of carer collaboration can only be provided if the consumer has a carer.

Care planning has been identified in the Office of the Chief Psychiatrist Clinical Reviews as an area for improvement. DHS agrees that this in part reflects a training issue. DHS is working with services to improve care planning and will also ask Area Mental Health Services to address the issue of the development of Individual Service Plans.

The relevant National Standard and Clinical Practice Guidelines 11.4.D.2 page 42 states:

“… the MHS provides access to a range of accepted therapies according to the needs of the consumer and their carers. Notes and examples: the MHSD should provide therapies or refer to another service provider; group or individual methods; psychotherapeutic; psychoeducational, family centred, rehabilitative and supportive therapies might be provided”

DHS and Area Mental Health Services support the delivery of psychoeducational services in a number of ways. Psycho-education has become an integral part of service delivery such that it is often woven into routine clinical contacts in such a way that it would not necessarily be documented. For example, a number of services are currently running carer groups. Similar input is also often provided by the PDSS sector, or carers are linked to other funded agencies such as Mental Illness Fellowship Victoria for information and mutual support. These activities tend to be poorly documented in individual patient files, so there are problems with Audit concluding that it is not happening at all.

DHS agrees that discharge planning processes and documentation need improvement. The Chief Psychiatrist has very recently issued Guidelines on “Discharge Planning for Adult Community Mental Health Services” (August 2002). These have been sent to all services. Guidelines specific to Aged Persons have been drafted and CAMHS guidelines will also be prepared.

The Audit conclusion that consumers were not linked in to appropriate services is not supported by the evidence. The evidence shows that lack of documentation is an issue. No conclusions can be drawn about whether consumers were or were not linked to appropriate services as Audit did not follow up consumers to check outcomes. Implementation of outcome measurement which is underway will address these issues.

Where patients being discharged from inpatient status are already under case management in the service, the discharge documentation is often in the form of a transfer summary or inter-service referral form. There is no mention of whether these documents existed in the services reviewed. They can be a most effective mechanism for aiding continuity of care.

Case closure is related to Discharge Planning and DHS would agree that this is an area in need of improvement.

More often there is some evidence of case closure and discharge discussions in the clinical notes, but these are not always well documented. It is an area for improvement, and will be assisted by the recent circulation of the Discharge Guidelines and the introduction of outcome measurement.

Recommendations

Urgency/Timeliness

The Department will continue to clarify definitions of urgency, timeliness and the nature of initial service response in line with the National approach and will continue to support Area Mental Health Service staff to implement agreed standards.

Emergency Departments

In the recently released New Directions for Victoria’s Mental Health Services the Department has identified action being taken to address issues for people with mental health problems attending emergency departments.

Monitor and Report on Service Provision

DHS agrees with Audit that outcome measures are important. As acknowledged by Audit, Victoria was the first jurisdiction to trial the use of routine outcome measurement, commencing with a small number of pilot agencies in the mid 1990s, and subsequent development of policy and training materials. An Information Development Agreement with the Commonwealth was signed in October 2001, providing $9.2 million to establish information infrastructure to support a national focus on service effectiveness, including the comprehensive introduction of outcome measures. The following diagram presents the expected progress in implementation of regular consumer outcome measurement within mental health services. Victoria leads the way in the implementation of outcome measurement in Australia. And when fully implemented in all States and Territories Australia is expected to be the first country in the world to have implemented outcome measurement across both the public and private sectors.

Victoria is aiming to have 70 per cent of Area Mental Health Services reporting outcomes data by June 2003.

In addition to implementing outcome measurement across Area Mental Health Services DHS will consider the measures and key performance indicators put forward by Audit.

Improve Duty Documentation

Action will be taken to assist AMHSs to improve duty documentation procedures and the Department will consider the specific areas for improvement identified by audit. Risk assessment guidelines are currently being developed by the Office of the Chief Psychiatrist.

Discharge practices

In 2002-03, new “sub-acute” service models are being developed and piloted in Melbourne and in a major rural centre. The pilots will offer 30 new sub-acute places, including bed-based services and, if needed, in-home support.

In order to improve the co-ordination and integration of services, the Department will work with mental health services to improve discharge planning and transition processes between elements of the system.

Implementation of Discharge guidelines recently issued by the Chief Psychiatrist will support improved discharge practices.

Demand Management Strategy

As identified in the New Directions for Mental Health document, in 2002-03, the Department has commenced development of a comprehensive demand management strategy for mental health services in metropolitan and rural Victoria.

Individual Service Plans/Treatment Plans

The Department will monitor and support AMHSs’ implementation and documentation of service delivery for Individual Service Plans, Case Closure plans and comprehensive assessments according to the National Standards.

Service Interface Initiatives

Many of the strategies and initiatives described in the New Directions for Victoria’s Mental Health Services report will support early intervention and relapse prevention for people with mental illness. For example, improved access to community-based services, in particular access to continuing care, case management and supported accommodation services, will assist in preventing crisis and relapse in people with mental illness. Victoria has the most extensive community-based services in Australia and has given priority to extending service interface initiatives with a range of service providers.

RESPONSE provided by Barwon Mental Health Service

Paras 3.20 to 3.22

These sections do not adequately describe the process currently used to screen, engage, assess and service clients who present to Barwon. Duty, intake and crisis assessment and response can be encapsulated in the one service response by, or facilitated by the one clinician. Barwon does not have a CAT but rather a 24-hour Triage service with on-call emergency backup. This difference is important in the context of the comparison results between the response times for services with a CAT and those with integrated team service structures. It is not accurate to leave the readers of this report with the view that the Duty, Intake model as described is the only model generally used.

Paras 3.39 to 3.43

The requirement that the service response only commences with a face-to-face response is very high. The service response will potentially start with inquiries into the history of the situation and liaison with many parties.

It may also be necessary to delay the Mental Health response due to other more pressing requirements, such as Ambulance/Police or Emergency medical response needs. It may also be prudent for the safety needs of staff or others involved not to attend immediately but wait for appropriate circumstances to be in place before attending a client situation. Cases initially defined as “urgent” may become less urgent as more information is attained or the situation changes. Barwon Mental Health Service does not accept the results of Table 3D and believe this table is distorted by lack of clarity about the definition of urgent.

RESPONSE provided by Goulburn Valley Area Mental Health Service

Para. 3.56

The service response to consumers in crisis and the outcome of that response has to be regarded in the context of the legislation. We operate within the “constraints” of the Mental Health Act and believe that there is a lack of understanding among the general population about what we can and cannot provide when a consumer does not wish to participate in treatment. Treatment must be provided in keeping with the philosophy of the “least restrictive environment” and this is often the point at which the service and the carers come into conflict.

Para. 3.67

Service to consumers in the Emergency Department (ED) is treated as a priority because the environment of that ED can be frightening and sometimes inappropriate for the client group. Response to ED is within one hour and not reliant on “medical clearance”.

Para. 3.68

The Department of Human Services funds the service to manage the more complex psychiatric illnesses/disorders, that are unable to be managed either in the private psychiatric system or by primary care providers. Historically, the general interpretation of the phrase “serious mental illness” did seem to concentrate on psychoses, however, this service does not preclude entry and assessment to persons suffering from a psychiatric illness other than psychosis. All presentations to the service are prioritised on the basis of a comprehensive assessment of needs rather than the provisional diagnosis.

RESPONSE by St Vincent’s Mental Health Services

The 1994 Mental Health Services Framework document focused on provision of public mental health services to the seriously mentally ill. Prior to this, community-based services traditionally had seen a wider group of consumers. With the move from institutionalised care to community care, it was necessary to ensure that those people with high levels of psychiatric disability received crisis intervention, assertive follow-up and case-management. This focus on serious mental illness has resulted in decreased responsiveness to those people with lower needs, however it should be recognised that people with psychotic disorders are likely to have higher needs because of the likelihood of disability and impairment as a result of illness. St Vincent’s Mental Health Service emphasises that it is need for services that dictates response, however, it is acknowledged that there is at times an over-emphasis on diagnosis as a factor. An improved response would require additional resources for appropriately trained staff.

Para. 3.7

It is incorrect to assume that because approximately 32 per cent of people who might be eligible are not accessing public mental health services, they are not receiving treatment. Many people choose to access private psychiatrists, general practitioners and other health providers rather than be treated in the public mental health system. Public mental health services have devoted considerable effort to improving linkages with these providers. In order to cope with the increased demand, when possible people whose mental health is relatively stable are referred to general practitioners and psychiatric disability support services for ongoing treatment, care and support. There has been an increased emphasis on shared care arrangements between public mental health services and GPs and private psychiatrists.

It is acknowledged that with improved resources, public mental health services could respond to unmet demand.

The lack of appropriate accommodation with support cannot be emphasised enough. Resources such as public housing, psycho-social and residential rehabilitation services, supported residential services, and home-based outreach support services are in short supply and not equitably distributed across the State. If accommodation and support needs were met more adequately, the need for acute clinical services would be likely to diminish.

The need for increased emphasis on early intervention for people experiencing the first onset of mental illness is crucial. The funding of one Early Intervention Clinician in each AMHS has been welcomed, however it is only the western suburbs of Melbourne that have access to a comprehensive early intervention treatment response. There is much evidence to indicate that early intervention can significantly decrease the level of impairment.

Para. 3.17

St Vincent’s Mental Health Service (SVMHS) aims to provide a career path for psychiatrists, by the creation of team psychiatrist roles which emphasise the provision of clinical leadership to community and inpatient teams. There is also the opportunity to become the authorised psychiatrist or Director of Clinical Services. Joint academic appointments are attractive to psychiatrists, however, a very limited number of these appointments are available. It is still extremely difficult to attract full-time psychiatrists with a commitment to public sector psychiatry as it is currently practised.

Chart 3B

This chart refers to non-urgent assessments. Urgent assessments at St Vincent’s Mental Health Service would not go through a 2-tiered response duty and intake.

Paras. 3.39 - 43

Mental health services in Victoria are working towards full compliance with the National Mental Health Standards, as they move from the Australian Council on Healthcare Standards EQuIP accreditation model to the National Mental Health Standards. Some services would aim to be fully compliant as they have already been through the accreditation process, others are working towards full compliance – SVMHS will go through the full accreditation process in March 2003, and some other services will not do this for 2 or 3 years. DHS should require all services to conform to national standards, whether they have been through the new accreditation process or not.

The National Mental Health Standard 11.2.12 does not prescribe a “face-to-face” contact. It states:“… The assessment process may be commenced with initial history taking, risk assessment, needs assessment over the phone”. Therefore, statements by the auditors regarding “lower standards” are incorrect. An urgent response does not necessarily mean a “face-to-face” contact within one hour. In some cases, a face-to-face contact may not occur in 24 hours, when it is difficult to locate a person. If potential extreme violence is involved, then police may attend urgently rather than mental health clinician, or if over-dose or other form of self-harm, it is likely to be more appropriate to call an ambulance immediately. The police, fire brigade and ambulance provide an emergency response which the Mental Health Service is not equipped to provide. The name “Crisis Assessment and Treatment Services” (CATS) has probably contributed to the common misperception that these teams provide an immediate emergency response.

Many factors need to be taken into consideration when dealing with an urgent referral. The CATS response is a planned one and is prioritised given the current work demands. Background information is needed and clinicians are reminded not to go into situations without this information due to safety reasons. It takes time to plan a response which involves consumers, carers etc. Where a “face-to-face” is not possible, telephone and co-ordination of supports are put into place. The “response” happens when the first intervention takes place – e.g. a phone call back to the referrer to discuss the plan.

Clarification and agreed guidelines should be developed by DHS in relation to what constitutes a response in this context.

There are often occasions where referrals deemed urgent can be further categorised into “very urgent” and “less urgent” which allows for prioritising of response when workloads are heavy and service demand is high. Response time is influenced by many factors, including urgency and risk (to consumer/carer and staff), current situation and context, consumer and carer wishes and availability, and availability of other service components (e.g. police or ambulance) as well as current service demand.

Meeting the demand for crisis response after-hours is a challenge for St Vincent’s Mental Health Service. At SVMHS it is recognised that the existing workloads are high and additional support is given to psychiatric triage during the evening shift by other CATS staff when needed and when possible. After hours response requires the triaging of all calls to the mental health service as well as assessment and treatment of people experiencing a mental health crisis. Many consumers contact the psychiatric triage services after-hours because they are lonely, find the night-time difficult to manage, and cannot sleep.

It is important to note CATS have to balance a number of duties. At any time, CAT services are seeing clients in their own homes for intensive follow-up, assessing new referrals in a range of settings, taking triage referral calls, attending clinical reviews and liaising with other services, GPs and private psychiatrists, and are involved in family work and support.

Para. 3.48

At St Vincent’s, a fast-track referral form has been implemented to speed up the referral in the Emergency Department (ED) to mental health triage when general health concerns are not present.

SVMHS has a good relationship with the ED, and presence of SVMHS clinicians is appreciated and valued, and the high demands on both services is recognised. In the Chief Psychiatrist’s clinical review of SVMHS, it was stated that:

“The Director of the Emergency Department reported the annual throughput of patients presenting to the Emergency Department with a primary psychiatric presentation as 1 200, with approximately 2 – 3 psychiatric patients treated in the Emergency Department at any one time. Overall he found the psychiatric input to be very good”.

There has been an increase in the police bringing consumers to the ED for assessment (under s10 of the MHA) which has increased demand for ED-based assessments.

Para. 3.59

Response should be related to need. St Vincent’s Mental Health Service aims to avoid the term “serious mental illness”. Considerable education, clinical supervision and policy development has been devoted to improving our response to people with personality disorder. However, it should be noted that those people diagnosed with schizophrenia, severe depression and those who have suicidal behaviour will be likely to receive a response for the simple reason that these conditions often require an urgent and specialised response that cannot be provided elsewhere in the health system. People with psychotic illness are likely to have highest need, experience greatest disability and impairment, have poorer physical health, and be more socioeconomically disadvantaged. They are a small group with high needs for mental health treatment.

Para. 3.60

Documentation of duty processes at St Vincent’s Mental Health Service was identified as a problem prior to the audit, and had been a focus of the Chief Psychiatrist’s Clinical Review. Documentation of these processes has now been improved. However, we believe that the previous poor documentation did not reflect a poor clinical response.

Chief Psychiatrist’s review said of Clarendon Clinic at SVMHS:

“Non-accepted referrals were reviewed daily (although there was no documentary evidence of this). CATS had access to management plans on an electronic database (that was available at all treatment locations) and there was a selection of management plans available to the duty-triage worker to facilitate more effective response. There seemed to be few if any barriers in accessing CATS involvement in acute or relapsing states and collaboration seemed excellent with all team components. In addition the service seemed responsive to community requests for treatment and care, and to display a genuine commitment to facilitating appropriate access”.

Para. 3.65

There is no common practice across AMHS in regards to ratings of urgency and risk self-harm. There is some debate about the use of ratings, and the danger of using forms which might preclude use of rigorous clinical judgement. At the very least, however, there should be a clear statement regarding urgency, and rationale for judgement. There should be standardised procedures across the mental health service system, and clarity about what must be recorded. Hopefully, the RAPID database will have some capacity to provide standardised documentation.

Para. 3.68

As indicated previously, people with psychotic disorders are likely to have higher needs for services. From our data, in our service, people with severe depression, anxiety, and personality disorders receive services in inpatient and community services. We would tend to refer people with severe eating disorders to specialist services, however, as we do not have the expertise within our service at this time.

Para. 3.75

The length of stay in the St Vincent’s Acute Inpatient Service has increased in the last year. The increase is attributed to the higher acuity level of patients, and the recognition that premature discharge results in unplanned re-admissions. The increase is also a result of 5 patients remaining in the Inpatient Service for 8 to 18 months due to a lack of appropriate treatment and accommodation options.

Table 3J

These results indicate major problems with documentation, some of these problems relate to short length of stay, high throughput and staffing shortages.

Paras. 3.78 – 3.81

For some patients, early discharge to CAT services is beneficial in ensuring that the person receives care with little disruption to their usual environment. CAT services and other community services offer an alternative to hospitalisation when possible.

At St Vincent’s, discharge planning is part of every patient’s management plan. Every consumer is discharged to follow-up, i.e. an AMHS, GP, private psychiatrist or Psychiatric Disability Support Service. Not all consumers are discharged to care by an AMHS.

In many instances, after the consumer has responded to effective psycho-pharmaceutical treatment, discharge is delayed due to psychosocial factors, lack of accommodation options or requests for families.

Lack of appropriate housing and support options is a major problem.

Paras. 3.88 – 3.91

It is commendable that the file audit results indicated that case managers were allocated to 97 per cent of registered consumers, and 2/3 were allocated within one day, and 1/3 after registration.

At St Vincent’s Mental Health Service, case-management allocations often take place at a clinical review meeting where the most appropriate case manager who has the capacity to take on further consumers is identified. Issues to be considered are preferred gender, professional discipline, intensity of intervention required. Assignment of case managers relates to the particular needs of the consumer, for instance consumers with more complex issues are assigned to more experienced clinicians. If interim intervention is needed, then the team manager, or the duty worker would take responsibility so there is always an identified contact for every person. In some cases, the CATS case co-ordinator would be the case manager.

Although consumers are discharged from public mental health services when their needs can be managed by other service providers, some consumers remain in the system for years, so some turnover of staff is inevitable even in a metropolitan service that has relatively stable staffing compared with outer metropolitan or rural areas. Inevitably, there is staff turn-over, especially in times of staff shortages. We aim to maintain consistent case-management as much as possible, particularly as we are dependent on psychiatric registrars for medical care who usually rotate every 6 months.

We aim to keep case-loads as low as possible in order to provide effective case management. Our ability to keep case-loads low is dependent on funding availability. We also aim to distribute cases to the most appropriate clinician.

Although the introduction of a consistent model of case management services across Victoria, lead to improved continuity of care, it is now time to redevelop this model to ensure that it operates flexibly and is able to utilise the specialist skills of all disciplines.

A more sophisticated approach emphasises a multi-disciplinary response, where a consumer may have an identified case manager who is responsible for care co-ordination, but where other inputs are provided by other team members, for instance, cognitive behavioural therapy, a comprehensive living skills assessment or a nursing intervention.

Each clinician will bring specialist skills to how they work with a consumer. It is simplistic to say that case management reduces specialist skills, rather we should say that effective case management should utilise the specialist skills of multi-disciplinary team members. There is little evidence that it is difficult to attract allied health workers, more that it is difficult particularly in rural and outer metropolitan areas to attract staff per se.

We would support a review of the case management model. Changes to the model would require full consultation, and preferably provision of system-wide training.

It is very concerning that the report suggests that case managers are reluctant to follow-up consumers. We view assertive follow-up as a core function of our community mental health services.

Para. 3.96

The absence of ISPs is very problematic. ISPs should be completed for all consumers in our Service; the only exception will be when consumers move with short notice to other areas soon after entry, and sometimes when only assessment or short-term care is provided and the consumer is referred to more appropriate services. Use of Inpatient management and treatment plans may sometimes substitute for an ISP in some cases.

Documentation problems are concerning, and are likely to be related to the increased demand on services where clinicians prioritise clinical service delivery over documentation.

Also the devolution to management by metropolitan health services and the disbanding of the central training unit resulted in less resources for training regarding clinical standards, less consistency across services, and limited leadership from the metropolitan health services which have tended historically to focus on hospital-based services, although they are shifting towards a broader view of integrated acute, sub-acute and community-based services.

Para. 3.100

It would appear that the auditors are using a very narrow view of what constitutes a psycho-social intervention, for instance provision of psychotherapy.

Apart from medical appointments where it is possible that only medication is discussed, or attendance to receive depot medication, all other involvement with AMHS would involve psychosocial interventions, for instance, supportive counselling, rehabilitation, home visits, referrals to Psychiatric Disability Support Services and other services, family work, and psycho-education. The auditors may be using a very narrow definition of non-drug interventions, for instance psychotherapy or CBT, which would not be provided to the majority of consumers.

It would appear to be self-evident, however, that if clinicians had more time they could provide a more intensive response. This is a matter of resources and access to appropriate training.

Paras. 3.114 – 3.115

Consumers presenting to St Vincent’s Mental Health Service have increasingly complex needs. Linkages with housing, welfare and income support agencies are essential. We have welcomed the establishment of the Northern Dual Diagnosis Service (Northern NEXUS) which has improved our ability to respond to the many consumers who experience substance use and mental health problems. The organisational structure at St Vincent’s Health enhances the links between Mental Health and Drug and Alcohol Services, with these services being part of the same Directorate.

Utilising the resources supplied by SPECTRUM in relation to consumers with personality disorders and the Victorian Dual Disability Service in relation to consumers with intellectual and psychiatric disability has also enhanced our ability to work with consumers with complex needs.

In our area, linking with agencies for homeless people has been essential, and we will be part of a pilot through the Victorian Homeless Strategy in which a SAAP-funded position auspiced by Outreach Victoria will work with our Inpatient Service in relation to provision of accommodation for homeless consumers following discharge.

In order to meet increased demand, AMHS need to maximise their linkages with other services, so that an optimal and complementary service can be provided.

St Vincent’s Mental Health Service has put considerable emphasis on fostering linkages, which has contributed to participation in a Primary Care Partnership Service Co-ordination Project to develop protocols between clinical and PDS Services in Yarra, and the successful submission by St Vincent’s Health for a Hospital Admission Risk Program project to work with people presenting with mental health and drug and alcohol problems presenting to the Emergency Department.

At St Vincent’s Mental Health Service, we recognise that we alone cannot meet the needs of consumers, so considerable effort and time is put into linking consumers with other services and working in collaboration with those services. For instance, St Vincent’s has increased the number of consumers linked to a GP in order to promote general health care.

¹ Victorian Department of Human Services, Mental Health Services in Victoria, the Framework for Service Delivery (1994).

² Victorian Department of Human Services, including Prism Records Information System Manager (PRISM, 1997-2000, and Victorian Psychiatric Disability Support Services Minimum Data Set, 1997-98 to 2001.

³ Victorian Department of Human Services, Revitalising Acute Inpatient Services: report of the review of adult acute inpatient mental health services (2000).

⁴ Psychiatric Disability Support Services Waiting List Register 1998 – 2000.

⁵ Victorian Psychiatric Disability Support Services Minimum Dataset 1998/99 to 2000/2001.

⁶ Evidence comes from interviews and focus groups conducted during the audit, and Department of Human Service report: Overview of findings from mental health focus group, October 2001-February 2002.

⁷ Commonwealth Department of Health and Aged Care, People living with a psychotic illness: an Australian study, 1997-1998, (1999).

⁸ Commonwealth Department of Health and Ageing, National Mental Health Report 2001 Draft Appendices Tables (2002).

⁹ Includes full-time equivalent staff employed in inpatient, ambulatory and community residential services.

¹⁰ Commonwealth Department of Health and Ageing, National Mental Health Report 2001 Draft Appendices Tables (2002). (Figure excludes Psychiatric Disability Support Service employees).

¹¹ Victorian Department of Human Services, Mental Health Services – Improved access through coordinated client care (1995).

¹² Victorian Department of Human Services, Mental Health Services: The Framework for Service Delivery (1994); Victorian Department of Human Services, Mental Health Services: Improved access through coordinated consumer care (1995); Victorian Department of Human Services, Mental Health Services: Psychiatric crisis assessment and treatment services, guidelines for service provision (1994).

¹³ RANZCP (submission to the audit) define mental health need as: “subjective distress, the disabling nature of the symptoms in terms of social and/or occupational functioning, symptom severity”.

¹⁴ Commonwealth Department of Health and Family Services, National Mental Health Standards (1996), standard 11.2, criteria 9.

¹⁵ The sample includes presentations of acute suicidality and deliberate self-harm, severe depression, substance abuse, acute psychosis, and severe situational crises with high risk of self-harm.

¹⁶ The average length of stay for a psychiatric patient in the ED at the Royal Melbourne Hospital between 14 April and 24 April 2002 was 17 hours. Three patients remained in the ED for 3 days. Source: Royal Melbourne Hospital Emergency Department (2002).

¹⁷ Australasian College of Emergency Medicine, Guidelines for the Management of Deliberate Self Harm in Young People (2000).

¹⁸ Data from 87 one hour interviews conducted with consumers from each of the 6 AMHSs audited. Consumer consultation methodology is described in Appendix A of this report.

¹⁹ There are 320 files for consumers classified as urgent for whom presenting problems were recorded. Note that this is a larger number than presented in Table 3D, since that table refers to 191 files which contained data on consumers who were rated as urgent and the timeframes for service provision.

²⁰ Victorian Department of Human Services, Clinical Review of Area Mental Health Services: review guidelines (2001).

²¹ Victorian Department of Human Services, New Directions for Victoria’s Mental Health Services: The Next Five Years, (September 2002).

²² Length of stay figures are calculated from information collected at service delivery level and entered into the Department’s IT systems. Data to 1999-2000 presented in Chart 3I were derived from the PRISM database and later data are derived from the RAPID database. There are doubts regarding the comparability of these data.

²³ Victorian Department of Human Services (2002).

²⁴ Victorian Department of Human Services, Victoria’s Mental Health Services, improved access through coordinated client care (1995).

²⁵ Victorian Department of Human Services, Mental Health Services: Crisis assessment and treatment services, guidelines for service provision (1994).

²⁶ Refers to non-drug treatments, such as cognitive behavioural therapy.

²⁷ Victorian Department of Human Services, Victoria’s Mental Health Services: improved access through coordinated consumer care (1995).

²⁸ Commonwealth Department of Health and Family Services, National Mental Health Standards (1996) – standard 8.2.

²⁹ Victorian Department of Human Services, Victoria’s Mental Health Services: improved access through coordinated consumer care (1995).

³⁰ Victorian Department of Human Services, Mental Health Services: improved access through coordinated client care (1995).

³¹ St Vincent’s and Goulburn AMHSs were an exception - rates of ISP documentation and consumer/carer involvement were higher than at other services.

³² Meadows and Singh, Mental Health in Australia: collaborative community practice, Oxford University Press (2001).

³³ Ibid.

³⁴ Commonwealth Department of Health and Family Services, National Mental Health Standards (1997); standard 9.

³⁵ Victorian Department of Human Services, Victoria’s Mental Health Services: improved access through coordinated consumer care (1996).

³⁶ Commonwealth Department of Health and Aged Care, People living with a psychotic illness: An Australian study 1997-1998, (1999).

³⁷ Australian Bureau of Statistics, Mental Health and Wellbeing Profile of Adults: Australia (1997).

³⁸ Revitalising Acute Inpatient services. DHS response and report of the Review of Adult Acute inpatient Mental Health services.