Evaluation of the mental health nurse incentive program
4.4 MHNIP model of care
Table of contents
4.4.1 The role of mental health nurses
4.4.2 Impact of eligible organisation structure on role and services provided
4.4.3 Connections and linkages with community support and social programs and activities
4.4.4 Links with other Commonwealth Government funded programs
4.4.5 Role delineation between MHNIP and jurisdiction- based mental health services
4.4.1 The role of mental health nurses
Mental illness reduces a person's capacity to carry out everyday activities, to work or study and to maintain relationships with family, friends, and the community. This places these individuals at higher risk of experiencing socioeconomic disadvantage, poor housing, abuse, neglect, discrimination, reduced access to healthcare and social isolation.19GPs and psychiatrists contacted through the case studies affirmed the difficulties they had in addressing the long-term treatment and support needs of many people living in the community with severe and persistent mental illness. This is because of the:
- high level of demand GPs and psychiatrists have for their services generally, over and above the services sought by people with severe and persistent mental illness;
- challenging nature of these patients, due to their complexity;
- difficulty medical practitioners sometimes experience in determining what types of treatment and support they are best placed to provide these patients; and
- constraints of the fee for service system that medical practitioners operate under in the private systems that limits the amount of time they can devote to supporting these patients.
- the flexibility of the Program Guidelines around identifying in scope patients; and
- the discretion available to nurses to see patients reasonably regularly, and for a flexible duration, in response to the specific needs of each individual.
Medical practitioners interviewed during the case studies supported these positive views about the impact of mental health nurses.
"I have received very good feedback from patients. The program allows for relatively greater intensity, particularly in the beginning. Psychiatrists do not have the same availability of time to dedicate to each patient. It is this intensity of service that accounts for a lot of the improvement"
Psychiatrist, private practice, regional New South Wales
"There has been a material improvement in the wellbeing of the patients supported by X [the mental health nurse]. I know him well and trust his judgement. It [the program ] does facilitate hospital avoidance."
GP, AMS, regional New South Wales
"The mental health nurse has greater flexibility to deal with issues. They can follow up and this relationship with the patient allows them to catch any early warning signs. Mental health patients are not getting as sick."
GP, general practice, regional South Australia
"The mental health nurse keeps patients out of hospital and provides better coordination. Initially I had a group of elderly patients with mental illness who would have frequent hospitalisations associated with their mental illness. The mental health nurse has assisted management of these patients and kept them out of hospital."
GP, general practice, regional Queensland
Key Finding 3: there is a high level of support from medical practitioners for the model of care embedded in MHNIP whereby mental health nurses, working in conjunction with GPs and psychiatrists, provide treatment and support to people with severe and persistent mental illness living in the community.
Top of pageThe Program Guidelines outline functions that a mental health nurse should undertake. They specify two categories of function: provision of clinical nursing services and coordination of clinical services. The Guidelines also state that mental health nurse functions are not limited to those listed activities.
The case study process sought to identify the most common activities undertaken by mental health nurses with respect to MHNIP patients. Table 4.2 shows the thirteen types of intervention used on more than half of the patients interviewed during the evaluation case studies. Psycho-education was used on nine out of every 10 MHNIP patients seen at case study sites but there was also a range of non-clinical services provided eg advocacy and liaison and support, and networking and collaboration.
There were a further 22 interventions identified in the case study process used on less than half of the patients interviewed.
Detailed finding #1: mental health nurses undertake both clinical and non-clinical activities to support their patients.
Table 4.3 shows the ranges of skills required by mental health nurses to apply the interventions listed above in Table 4.2.
Detailed finding #2: mental health nurses require a broad range of skills to perform their role under MHNIP.
The ACMHN advised that mental health nurses often have responsibility for establishing policies, procedures reporting and preparing program audits. Mental health nurses provided feedback to ACMHN that there is a lack of support, resources and information available to support them in these activities.
Details of a patient case study are provided in Figure 4.1 to demonstrate the role and impact mental health nurses can have on participating patients.
Throughout the evaluation there were supportive comments from both consumers and their carers on how the MHNIP model of care affected them.
"He [the mental health nurse] sits me down to talk about the past. After that he tries to talk to me about not thinking about suicide. He tells me to go for a walks when I'm angry. He said 'Go and do something instead of taking the tablets.'
I don't know how to put it into words. He's been real helpful. He worries about me."
Patient, general practice, Tasmania
"Having a doctor and a disability pension is not enough. I need support".
Patient, metropolitan New South Wales
"It [MHNIP] has impacted on C [ the patient] so much. He used to refuse to come to the service [an AMS]. Dr B put him in contact with M [the mental health nurse]. I thought he was beyond help. I was sceptical about getting another counsellor. I road tested him [the mental health nurse]. I felt so relieved. M has saved our relationship. It has only been three months. He has turned C around. C has given up [non-prescription] drugs and it's been good for him to see [ that he can function without drugs]. C is seeing M every Friday afternoon. If you know anyone with schizophrenia, they don't want to leave home. He was constantly paranoid.
[But things have changed.]..... Last week he went and did the grocery shopping. I was so proud of him. Come and walk a day in my shoes and you'll see it [MHNIP] actually works".
Carer of a client using MHNIP, AMS, regional New South Wales
Peak bodies whose membership operates in the primary and specialist mental health area, including the Royal Australian and New Zealand College of Psychiatrists and the General Practice Mental Health Standards Collaboration, Royal Australian College of General Practice, also affirmed their strong support for the program.
Key Finding 4: patients, carers and relevant peak bodies are also supportive of the model of care underlying MHNIP.
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Table 4.2: Mental health nurse interventions applied to MHNIP patients, based on experience of patients interviewed during evaluation case studies
Table 4.2 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.Percentage of patients receiving interventions applied in a sample of case study patients:
- Psycho-education - 92.3%
- Engages consumer in their care /treatment plan to support their recovery - 88.5%
- Liaison and support for patients, family, carers and other professionals - 84.6%
- Acceptance and Commitment Therapy (Mindfulness) - 80.8%
- Medication administration and management (including managing compliance) - 80.8%
- Liaison, networking, collaboration and managing referral to other services - 80.8%
- Advocacy - 80.8%
- Cognitive Behavioural Therapy - 76.9%
- Brief Solution Focused Therapy - 76.9%
- Managing co-morbidities - 69.2%
- Motivational interviewing - 61.5%
- Suicide prevention - 61.5%
- Joint sessions with GP and other health professionals - 53.8%
Source: case study interview, mental health nurses
Table 4.3: Skills required by mental health nurses
Percentage of patients where skills were need to support the provision of interventions applied to a sample case of study patients:- Pharmacology - 100.0%
- Psycho-education - 100.0%
- Physical health care - 92.3%
- Establishing a therapeutic relationship - 88.5%
- Mental Health Assessment and monitoring - 88.5%
- Care and treatment planning - 88.5%
- Risk Assessment and monitoring - 88.5%
- Awareness of health care environment and other services - 88.5%
- Treatment team coordination, supervision, and case discussion - 88.5%
- Health promotion and coaching - 84.6%
- Develop a nursing diagnosis and or contribute to the clarification of diagnosis. - 80.8%
- Pre and post outcome monitoring - 76.9%
- Collaboration with consumers, carers, stakeholders to develop partnerships - 73.1%
(Source: case study interview, mental health nurses)
Top of pageFigure 4.1: Case study: an example of how the MHNIP model of care works
Ms X is a client of a private psychiatry practice and has been accessing MHNIP services for four years. Her HoNOS measure a year ago was rated at 14. Her current MHNIP care needs are classified as medium, with a current HoNOS measure of 10. Ms X now has contact with the mental health nurse once a week, through a combination of clinic visits and by telephone calls.Prior to joining the MHNIP, Ms X had one hospital admission in relation to her mental health illness. Since being in MHNIP, there have been no hospital admissions. Over the last 12 months, through her interaction with MHNIP, has:
- stabilised medication use;
- improved family interaction; and
- been supported to find part-time employment.
"[Stepping Stones] is good. It provides peer support."
Over the past year, interventions used by the mental health nurse to support Ms X included:
- acceptance and commitment therapy
- advocacy
- brief solution focussed therapy
- cognitive behavioural therapy
- conflict resolution
- engaging consumer in care plan
- group therapy
- liaison, networking, collaboration and refer to other services
- managing comorbidities
- medication administration and management
- motivational interviewing
- psycho-education
- suicide prevention
- awareness of health care environment and other services
- care and treatment planning
- establishing a therapeutic relationship
- health promotion and coaching
- mental health assessment & monitoring
- pharmacology
- physical health care
- pre & post outcome monitoring
- psycho-education
- risk assessment & monitoring
- treatment team coordination, supervision, and case discussion
"I would have lost my job if not for the mental health nurse"
Source: Evaluation case study
Top of page4.4.2 Impact of eligible organisation structure on role and services provided
Chapter 3, section 3.2.1 described the different types of organisation eligible to participate in MHNIP and involved in the case study process. HMA found that the eligible organisation type had a minor impact on the operations of the triaging process, prior to acceptance of a patient into MHNIP to receive care:- in eligible organisations operated by a psychiatrist, GP or an Aboriginal Medical Service (AMS) a medical practitioner was always involved in the initial assessment of patient eligibility for MHNIP. After this initial assessment by the medical practitioner, the patient was then referred directly to the mental health nurse for preparation of a detailed care plan; and
- a small variation in this process was observed where the eligible organisation was a Medicare Local and was engaged with more than one mental health nurse. In this situation a mental heath nurse coordinator employed within the Medicare Local allocated the patient to a mental health nurse, after the initial assessment by a medical practitioner.
Detailed finding #3: the care provided by a metal health nurse was not affected by the nature of the eligible organisation.
The proportion of services delivered and mental health nurses by eligible organisation type is presented in table 4.4. This information is for a two year time frame, 1 July 2009 to 30 June 2011. It is indicative only as aspects of the source data from DHS could not be reconciled.
This data reveals just over 80% of MHNIP services were delivered through General Practices and Medicare Locals (formerly Divisions of General Practice). Likewise, they account for the largest number of mental health nurses and MHNIP sessions. At the other extreme, Aboriginal Health Services have had minimal involvement in MHNIP over the time period reviewed.
Key Finding 5: General Practices and Medicare Locals (formerly Division of General Practices) accounted for the largest proportion of MHNIP services delivered (80.9%) and mental health nurses employed (76.4%) between 1 July 2009 and 30 June 2011.
Table 4.4: Proportion of MHNIP services delivered and mental health nurses engaged by eligible organisation type, 2009-2011
| Eligible Organisation Type | % of MHNIP servicesa | % MHNIP sessionsrb | % Mental health nursesc |
|---|---|---|---|
| General practices | 53.5% | 43.2% | 40.8% |
| Division of General Practice / Medicare Local | 27.4% | 34.0% | 35.6% |
| Private Psychiatry Practice | 15.9% | 16.2% | 19.8% |
| Private Hospital | 2.3% | 4.7% | 3.0% |
| Aboriginal Health Service | 0.9% | 1.9% | 0.9% |
| Total | 100% | 100% | 100% |
(Source: DHS)
a A service represents treatment provided by a mental health nurse to a MHNIP patient. It can be provided in a range of settings, such as in clinics or at a patient's home and also by telephone. Services include clinical nursing services and coordination of clinical services for patients with a severe and persistent mental disorder.
b A session represents 3.5 hours and is the basis for claiming the MHNIP sessional rate. A fulltime mental health nurse works 10 sessions per week, with an expectation of having an average nurse caseload of at least two individual services to patients with a severe and persistent mental disorder per session.
c Mental health nurse data is calculated on the unique identification numbers on the claim forms, and therefore does not represent a measure of fulltime equivalence. Therefore caution is needed when comparing the proportion of services and mental health nurse columns.
4.4.3 Connections and linkages with community support and social programs and activities
All mental health nurses consulted during case studies said they referred patients to other support programs. Mental health nurses are able to make these connections because they have a strong understanding of local service delivery networks. The case studies identified a range of programs to which mental health nurses refer. These included:- Centrelink;
- public housing services;
- drug and alcohol services;
- employment agencies;
- disability employment services; and
- psychiatric disability and rehabilitation support services operated by NGOs such as the Salvation Army and NEMII.
Detailed finding #4: mental health nurses have local knowledge of what programs, community supports, and social activities are available to support the patients they see through MHNIP. Their capacity to make these links, based on service availability, varies by geographic area and jurisdiction.
The case study process suggested there was less general awareness of newly emerging programs like PHaMS.
Detailed finding #5: there is scope for greater social marketing of new programs, like PHaMS, that may be of assistance to people with severe and persistent mental illness.
4.4.4 Links with other Commonwealth Government funded programs
The survey of medical practitioners and mental health nurses revealed a consistent pattern of awareness around other Commonwealth programs that provide funding to support people with mental illness.The medical practitioner survey identified that GPs and psychiatrists use MBS Items to deliver preparation of a mental health plan for MHNIP patients.
The case studies revealed that many GPs consciously triage their patients to different support programs based on clinical need: patients triaged to MHNIP, as expected, were placed on that pathway because of their severe and persistent mental illness (see section 5.4.2 which discusses processes for patient selection). There was some evidence that Medicare Locals triage at the sub-regional or regional level, promoting greater uniformity of access across the geography. GPs said that patients referred directly to Better Access or ATAPS were more likely to have mild to moderate mental illness.
"They [the different Commonwealth funded programs] are for a different sub-types of population. Depends on what fits best with the patient."
GP, metropolitan Tasmania
"We use ATAPS for mild depression - less risky patients. MHNIP sits between ATAPS and acute mental illness."
GP, metropolitan Queensland
"I refer to Better Access or ATAPS. But if patients are severe enough I refer to M [the mental health nurse] or hospital if they're really bad."
GP, AMS, regional New South Wales
"It's one of a kind in this space. Patients would fall through the gap if not for MHNIP. It's targeted at the right level, between acute and community psychiatric services."
Mental health nurse, regional Queensland
Top of pageThese triage pathways are appropriate and reflect the underlying targeting of the different mental health programs. GPs advised that they maintained overall responsibility for clients who receive services under MHNIP as their treating physician in accordance with the requirements of the Mental Health Treatment Plan.
Key Finding 6: there was evidence that medical practitioners are triaging patients to different Commonwealth funded programs supporting people with mental illness, based on clinical need. This included utilising MHNIP for patients with severe and persistent mental illness, and referral of patients with lower levels of disability to support from other appropriate services.
During consultations both the Royal Australian and New Zealand College of Psychiatrists and the ACMHN it was noted that there was scope to improve pathways for patients from MHNIP to ATAPS and other appropriate services where their condition improves. This is consistent with the ATAPS Program Guidelines:
A person with severe mental illness whose condition may benefit from focussed psychological strategies may be provided with ATAPS services.....When a person has a long term (persistent mental illness) ATAPS may not be able to meet their needs over time.
HMA only observed this linkage at one case study site, as described below:
"MHNIP patients may access ATAPS through their 'healthier' periods - but not at the same time. They may also access alcohol and drug services as the patient may need to detox prior to medication management."
Mental health nurse, metropolitan Queensland
Promoting appropriate linkages between MHNIP and other services, together with ensuring patient care is consistent with MHNIP exit criteria, could have broader benefits by increasing patient flows through MHNIP.
Detailed finding #6: there is an opportunity to improve the pathways of patients from MHNIP to other appropriate services where their condition has improved.
4.4.5 Role delineation between MHNIP and jurisdiction- based mental health services
In Australia, the mental health system is delivered by a combination of Commonwealth and State and Territory Government programs. In broad terms, the Commonwealth's current role is to:- provide policy and funding leadership for primary mental health care and subsidise access to private specialist care (including in private hospitals);
- provide leadership in supporting national effort such as monitoring reporting, data collection and policy and planning;
- drive workforce development; and
- provide employment and education support by;
- funding specific programs targeting priority areas such as suicide prevention, as well as programs for specific groups such as young people, and detainees; and
- to fund income support, housing and other broader community services.
Representatives from jurisdiction based mental health services were not interviewed during the evaluation. However, case study meetings revealed anecdotal feedback from MHNIP service providers and patients about their interaction with state based mental health services.
Some of the mental health nurses interviewed worked in state based mental health prior to being engaged under the MHNIP. These nurses said that they continued to liaise and work with state based mental health around particular needs of their patients, for example:
- accessing acute care teams if and when required, if the condition of their patient deteriorated;
- seeking assistance from state health mental teams as a point of contact for clients when the nurse took annual leave; and
- accessing information about patients that may have been cared for under the state mental health service prior to commencing with the MHNIP.
The frequency of communication with state mental health services varied depending on location of the MHNIP eligible organisation and accessibility of services.
Many MHNIP clients interviewed reported they had previous contact with state and territory mental health services. A number said they sought to avoid those services. Reasons that they gave were:
- they found state and territory mental health service staff frequently changed (due to staff turn-over and shift arrangements), which meant they were seeing different clinicians; and
- turnover of staff meant clients were often having to re-tell their stories.
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