Evaluation of the mental health nurse incentive program
Appendix B: exploration of evaluation findings against key themes of previous MHNIP evaluations and reports
Table of contents
- Abbreviations
- Glossary
- Executive summary
Part A: evaluation context
Part B: evaluation findings- Appendices
- Appendix A: link between the statement of requirement and the evaluation report
- Appendix B: exploration of evaluation findings against key themes of previous MHNIP evaluations and reports
- Appendix C: comparison of with ATAPS clinical governance framework
- Appendix D: excerpt of NSW public health system nurses' and midwives (state) award 2011
- Appendix E: MHNIP cost analysis: description and findings
- Appendix F: variability in HoNOS scores at time of entry
- References
This appendix compares the current evaluation findings against the key themes from the following evaluations and project:
- Evaluation of the pilot of Mental Health Nurse Incentive Program in the Private Hospital Setting; and
- Case Studies Report.
Table 8.2: Key findings of the Pilot of the MHNIP in the Private Hospital Setting – comparison with the findings of this evaluation
Table 8.2 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.Strengths and weaknesses of the model
Key finding – evaluation of the pilot of the MHNIP in the private hospital setting
Qualitative and quantitative feedback has identified strong endorsement of the model underpinning the MHNIP Pilot in private mental health settings. This is seen to benefit clients and their significant others as well as the private mental health system.There is agreement between mental health nurses and coordinators, and psychiatrists and GPs about the strengths of the MHNIP Model, including:
- Enables more effective crisis intervention
- Provides accessibility to mental health services for clients unable to access or rejected by public MH services
- mental health nurses fill a gap in the private mental health service system
- Is a means of providing support and continuity to clients in hospital
- Enables more holistic care (e.g. through links to the community services and other supports in client's environments)
- Provides a free service to clients
- Clients have access to an increased range of mental health services
- Accessibility is greatly enhanced through provision of home based service
- The initiative is resource effective (e.g. substituting MHN time for psychiatrist/GP time)
- Is expected to reduce the total number of hospital admissions for mental health problems
- The guidelines are sufficiently flexible to support innovative service provision
- The mental health nurse role in medication monitoring reduces time spent by GPs/psychiatrists on this
- Reduces the waiting time for psychiatrist services
- Is expected to reduce the total number of hospital bed days for mental health problems
- Provides enhanced accessibility to mental health services for clients of other disadvantaged backgrounds
- Enables streamlined access to psychiatrists
- addresses gap in mental health service provision for Indigenous clients
- Lack of security in pilot status – e.g. inhibits recruiting of mental health nurses who are already scarce in supply
- Lack of Medicare funding for case management meetings and discussions between psychiatrists and MHNs
- The requirement to service two clients within one session (i.e. half day ) is problematic in rural areas due to distance
- Reliance on auspice's infrastructure e.g. cars, accommodation - not able to stand alone facility
- Lack of Medicare funding for coordination and follow up work by
- Not being promoted effectively to GPs, resulting in limited understanding of MHNIP
MHNIP services have been very responsive and supportive to their clients, providing significantly shorter waiting times than would occur in relation to seeing a psychiatrist.
Where home-based visits were being provided, the MHNIP model offered significant accessibility and flexibility in its mode of delivery for clients. From a clinical perspective, the opportunity to increase service providers' understating of clients' home environments is also provided. However, home-based delivery does bring increased risks for Mental Health Nurses, associated with travel and with safety in relation to some clients. The time and costs associated with home-based delivery make it more expensive than a clinical based delivery mode.
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HMA Observations based on the evaluation findings
Similar views were expressed by mental health nurses, general practitioners and psychiatrists and clients during the case study process and surveys (MHN and medical practitioners).Findings from the Pilot are strengthened and supported by the findings of this evaluation. Specifically, the total number of inpatient bed days for mental health problems was reduced by an average of 3 days (95% CI -5.57 – 0.078) for a sample collected as part of the cost analysis. This is indicative only, as this was based on a small sample that is not representative.
Although fundamentally different, the weaknesses of the Pilot model – particularly the lack of program security, issues with funding and insufficient promotion – were echoed by stakeholders during this evaluation.
These views were reinforced by clients during the case study process, with many saying that they would like more time with the mental health nurse.
The flexibility of the MHNIP model was cited by clients, mental health nurses and medical practitioners as a key strength. This included the ability for the MHN service to adapt quickly to the changing needs of the client.
MHNIP offers the flexibility for mental health nurses to meet clients in a variety of locations. Many nurses reported meeting their patients outside an office setting, including at the client's home, coffee shops and at parks. Mental health nurses who do not meet clients outside of the office environment cited insufficient funding as one of the main reasons they did not provide home-visits. The increased risk for mental health nurses was also cited as key reason for not offering home-visits.
Employment of mental health nurses in MHNIP
Key finding – evaluation of the pilot of the MHNIP in the private hospital setting
Mental health nurses and coordinators assigned a high degree of importance to the following roles:- Monitoring clients' mental health and wellbeing
- Face-to-face sessions with clients
- Client education
- Advice and general information
- Meetings and information exchange with psychiatrists
- Post-discharge follow up of clients
- Administration relating to MHNIP
- Support and education to clients and their families
- Referral/linkage of clients to other services in the community
- Provision of information and advice to assist in self-management of mental health issues
- Provision of support not elsewhere received
- Help with understanding and managing medication
When asked about job satisfaction and conditions of employment:
- The lowest average rating was applied to opportunities for future training and development, followed by;
- Security of employment and salary and financial benefits, and
- Opportunities to develop specialised skills and knowledge on-the-job
HMA Observations based on the evaluation findings
The roles, activities and services reported by mental health nurses in the Pilot project are closely aligned to the roles reported by nurses in both the survey and case studies conducted as part of this evaluation.The requirement for credentialing by ACMHN was seen as necessary by participants in the case study and survey process. However, many suggested that professional development and continuing education was difficult to sustain under the funding provided for MHNIP.
Opportunities for future training and development, security of employment and salary and financial benefits were viewed as a potential weakness of working under the MHNIP. Others said that they found it difficult to find a practice that was willing to employ a metal health nurse under the program due to this uncertainty and lack of financial benefits, with many of these nurses being 'engaged' rather than 'employed' by the organisation.
Impact on the private mental health service system
Key finding – evaluation of the pilot of the MHNIP in the private hospital setting
The majority of participating psychiatrists and GPS believe that the MHNIP has made a positive impact in a number of ways, but in particular, in relation to their capacity to deal with complex cases, increased involvement with others involved in client's care, and the achievement of a more timely response to acute or emergency presentations.Qualitative and quantitative feedback from the three main key stakeholder groups identified strong endorsement of the model underpinning the MHNIP Pilot in private mental health settings. This is seen to benefit clients and their significant others as well as the private mental health system. The Mental Health Nurse role has been found to fill a gap in the private health system and to have had an extremely positive impact on clients to have bought a number of benefits to referring psychiatrists and GPs. This positive impact is seen by all three groups of stakeholders as able to be extended through resourcing improvements.
It is evident that all three groups, representing the key stakeholders in MHNIP, have positive views about the impact of the Program on client outcomes. This is despite the difficulties associated with implementing the program as a pilot.
MHNIP has had a positive impact on the health and well-being of most of its clients, based on statistically significant changes in HoNOS scores following entry to the Program, and based on the interview and survey feedback of MHNs, clients, and psychiatrists and GPs.
Should the MHNIP become an on-going component of the private mental health system, it will be important that its resourcing is less reliant on goodwill and altruism and more reliant on funding that acknowledges the range of inputs required.
HMA Observations based on the evaluation findings
These findings are supported by this evaluation, with many citing that the mental health nurse gave them the confidence to deal with the more complex cases often keeping these clients in the community.Quantitative and qualitative feedback received as part of this evaluation supported the view that MHNIP filled a gap in service delivery for patients with a severe mental illness and contributed to positive patient outcomes.
HoNOS scores were received from only 87 of the 267 patients included in the cost analysis on both entry to MHNIP and at 12 months later. HoNOS scores fell from an average of 13.7 on entry to MHNIP, to 10.1 at the end of the first 12 months of MHNIP treatment.
There are a large number of uncosted and intangible benefits associated with MHNIP including the impacts of improved patient outcomes, enhanced relationships with carers and family members, and the effects on carer social security outlays. Examination of these impacts would require an extensive enhancement to existing data collection processes. The evaluation findings suggest a comprehensive economic analysis would find these benefits to be positive.
Many participants in the case study and survey processes strongly advised that the feel level no longer provided an incentive to participate in the program. The lack of indexation means organisations have experienced a real decrease in the sessional fee value and mental health nurse salaries have increased over time.
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Table 8.3: Key findings of the NACMH case studies project – comparison with the findings of this evaluation
Funding
Case study report findings
- Services experienced difficulties with the funding formula being limited to covering salary and on-costs under the MHNIP Program Guidelines.
HMA observations based on the evaluation finding
- Similar views were expressed during the evaluation survey and case studies.
Interpretation of the program guidelines
Case study report findings
- Interpretation of the Program Guidelines varied across sites.
- In particular "not all service users appear[ed] to be at risk of hospitalisation."
HMA observations based on the evaluation finding
- Level of acuity for patient entry into the program appeared to vary across some sites.
Service models
Case study report findings
- There was a range of employment models for mental health nurses
HMA observations based on the evaluation finding
- Different employment models had some impact on triage processes
- This did not affect the underlying model of care provided to patients accepted into the program: mental health nurses, working in conjunction with GPs and psychiatrists, provided treatment and support to people with severe and persistent mental illness living in the community.
Workforce
Case study report findings
- Mental health nurses need the ability to work autonomously and collaboratively with doctors and other health professionals.
HMA observations based on the evaluation finding
- There were similar observations during the evaluation survey and case studies.
Data collection
Case study report findings
- Mental health nurse interventions were recorded into patient management systems.
- HoNOS data was not routinely entered into a database or examined for service improvement purposes.
HMA observations based on the evaluation finding
- HoNOS data was routinely collected but not regularly used for service improvement purposes.
- The evaluation collected HoNOS scores for a sample of patients from a selection of case study sites.
- The evaluation found that HoNOS data could be used to provide useful insights into the operations and impacts of MHNIP at a program level.
Mental health outcomes
Case study report findings
- There were anecdotal reports that inpatient episodes had reduced for clients.
HMA observations based on the evaluation finding
- Quantitative evaluation evidence showed overall mental health hospital admissions decreased by 13.3% for a sample of MHNIP patients in the 12 months following their involvement in the program. This was not true for all conditions: bipolar disorders showed a slight increase in the number of admissions.
Other health outcomes
Case study report findings
- Clients reported better overall physical health after becoming involved in MHNIP
HMA observations based on the evaluation finding
- There were similar observations during the evaluation survey and case studies.
Consequences / impact
Case study report findings
- GPs experienced greater throughput in their practice.
HMA observations based on the evaluation finding
- There were similar observations during the evaluation survey and case studies.
Access / barriers
Case study report findings
- A range of factors promoted access to the program and act
HMA observations based on the evaluation finding
- There were similar observations during the evaluation survey and case studies.
Partnerships
Case study report findings
- Mental health nurses were linking patients with other services.
HMA observations based on the evaluation finding
- There were similar observations during the evaluation survey and case studies.
Sustainability
Case study report findings
- There were concerns about how long the program would operate.
HMA observations based on the evaluation finding
- There were similar observations during the evaluation survey and case studies.