Evaluation of the mental health nurse incentive program
5.10 Compliance controls
Table of contents
Compliance controls for eligible organisations are outlined in the Program Guidelines. Each organisation must keep records and evidence which, if requested by DHS, would demonstrate compliance with the Guidelines.
5.10.1 Patient eligibility
5.10.2 Mental health nurse caseload
5.10.1 Patient eligibility
Case study organisations indicated medical practitioner referrals were always received for MHNIP patients. They may take different forms, such as completion of a referral form, referral via verbal comments or email, or advice in case notes. It was common for the medical practitioner to seek input by the mental health nurse to assist in determining if a patient was suitable for MHNIP or for another program, such as ATAPS.Feedback from medical practitioners suggested they refer their most difficult mental health cases to the mental health nurse. They are more likely to retain full management of patients with less severe mental health disorders. Case study findings suggest that the majority of MHNIP patients comply with eligibility requirements.
Detailed finding # 25: medical practitioners take responsibility for assessing patient eligibility for MHNIP treatment.
A small proportion of the case study organisations interviewed reported that some of their patients might not strictly meet the eligibility guidelines. Nevertheless, they felt it was appropriate to manage such patients under MHNIP as:
- they had multiple comorbidities, addictions, dual diagnosis (anxiety / depression) and a range of other issues (eg homelessness);
- there were limited or no other appropriate services to access; and/or
- if left untreated, these patients were at risk of hospitalisation.
The ACMHN observed, in response to these findings, that many mental health nurses are aware that HoNOS measures are not being collected and used for service planning or evaluation. Therefore, it is possible that many do not place importance on their collection.
HMA further observed that while HoNOS scores do not relate to the eligibility criteria for MHNIP, they do add some qualitative evidence to the findings reported by case study sites.
Detailed finding # 26: there was some evidence of variability in mean HoNOS scores on patient entry to the program, suggesting there is scope for promoting a more consistent approach to assessing eligibility across sites. Clinical governance processes, including cross-site case review processes, could be used to promote this greater uniformity.Top of page
5.10.2 Mental health nurse caseload
The Program Guidelines contain a large list of elements associated with the expected caseload of mental health nurses. Evaluation observations for each element (shown in italics) are provided below:- A mental health nurse can be employed for between one and ten sessions per week. The evaluation found no evidence to the contrary. However, DHS reported instances where:
- mental health nurses were working for more than one eligible organisation and collectively have more than 10 sessions per week; and
- some mental health nurses have claimed more than 10 sessions per week at the one eligible organisation, as the organisation provides access to MHNIP services after business hours and on weekends.
Detailed finding #27: the majority of mental health nurses comply with the employment conditions in the Guidelines around the maximum number of sessions per week.
An eligible organisation could be offering access to mental health nurse services outside normal business hours, equating to three sessions per day. Including a Saturday for another two sessions could result in 17 sessions in a week (59.5 session hours). Whilst it may seem unsafe to allow a mental health nurse to work up to 17 sessions in a week, it is reasonable to work more than 10 sessions. The ACMN suggested that, given the seniority and autonomy of the role, mental health nurses could be given greater responsibility over their own safe work practices, supported by the development of strong clinical governance arrangements. Flexibility to enable services to be provided outside of normal business hours needs to be balanced against the need to comply with the Work Health and Safety Act 2011.
Detailed finding #28: consideration could be given to expanding the current mental health nurse employment conditions allowing them to provide greater than 10 sessions per week to enable eligible organisations to offer MHNIP services out of hours and on weekends.
- mental health nurses were working for more than one eligible organisation and collectively have more than 10 sessions per week; and
- Each mental health nurse should have an average nurse caseload of at least two individual services to patients with a severe and persistent mental health disorder per session. Individual services include face-to-face and telephone consultation. Mental health nurses interviewed during case studies reported being very busy and but able to meet this requirement comfortably.
Detailed finding #29: mental health nurses comply with caseload requirement of at least two individual services to patients per session.
During the case studies some mental health nurses said they claimed a maximum of two patients per session, regardless of how many patients they actually supported during that period. The reason given was that any additional information above two patients was irrelevant: this did not affect funding levels and it reduced the administrative and data input they had to enter. This was also an observation reported by the ACMHN. This has important implications for evaluating the impact and reach of the program relative to their level of treatment, as the true level of services provided to patients is unknown.
ACMHN reported it had received feedback from mental health nurses demonstrating an unintended consequence of the requirement of at least two individual services to patients per session. If a patient requires unplanned support due to a crisis or increased acuity, the mental health nurse cannot claim this time as a session because it is not a service to two clients. This has the potential to detract from the flexibility of the program.
Detailed finding #30: compliance around completing the claim form could be improved to capture data on all mental health nurse patient activity.
- A full-time mental health nurse should have a current minimum case load of 20 individual patients with a severe and persistent mental health disorder per week, averaged over three months and, the expected annual caseload managed by a full‑time mental health nurse is 35 patients. During the case studies mental health nurses reported they met this requirement. In case study interviews it was common for mental health nurses to state they had more than 20 active MHNIP patients that they were managing.
Detailed finding #31: mental health nurses are meeting the compliance requirements relating to the minimum caseload (number of individual patients) per week and over the year.
- full-time mental health nurse engaged for 10 sessions per week would provide an average 25 hours of clinical contact time per week, with the balance of time spent in related tasks including interagency liaison, case planning and coordination, clinical briefings to relevant general practitioners and/or psychiatrists, and travel. Mental health nurses interviewed during the case studies were asked to estimate how they spend their time on average across the elements listed above. Some mental health nurses were very aware of the need to have 25 hours (or 71.4% of their time) spent on clinical contact.
The case studies found an average of almost 70% of time was allocated to clinical contact (ranging from 53% to 85%). Within this over-arching category care planning and coordination was the activity with the largest allocation of time, with an average of 9.2% (ranging from 6% to 12.5%), followed by interagency liaison with an average of 8.5% (ranging from 2% to 15%).
Detailed finding #32: mental health nurses are, on average, allocating 25 hours per week to clinical contact, consistent with the requirements of the Program Guidelines.