Evaluation of the mental health nurse incentive program
5.4 Process of care
Table of contents
5.4.1 Patient pathway to MHNIP services
5.4.2 Patient selection
5.4.3 Care plans
5.4.4 MHNIP treatment duration
5.4.1 Patient pathway to MHNIP services
The case study process identified a common patient pathway to access MHNIP services. This was:- a new patient was seen by the medical practitioner, triaged and referred to either MHNIP or another mental health program, such as ATAPS;
- in the case of MHNIP, the GP prepares a mental health care plan along with a referral to the mental health nurse;
- the patient makes an appointment with the mental health nurse where the care plan is reviewed, discussed and a treatment and support plan prepared;
- the mental health nurse provides a copy of the treatment and support plan to the medical practitioner; and
- the mental health nurse works with the patient according to the plan. Referrals are made to external programs and service providers as per the treatment plan.
- varying degrees of input by mental health nurse into the medical practitioner triaging decision of whether a patient is suitable for MHNIP;
- mental health nurse assistance in preparation of the mental health care plan; and
- the mental health nurse may have a first appointment with the patient on the day of presentation, to assist manage an immediate crisis.
Psychiatrist, private psychiatry practice, metropolitan Queensland
Detailed finding #14: there is scope for ensuring greater consistency in processes of patient care by strengthening the Program Guidelines and enhancing clinical governance requirements.Top of page
5.4.2 Patient selection
Interviews with medical practitioners at 15 of the case study sites (88.2%) found that they selected patients for the program based on their high acuity and persistent mental illness, in accordance with the MHNIP Program Guidelines eligibility criteria."We follow the guidelines. Our mental health nurse sees the more severe cases. Most of our MHNIP patients have borderline personality disorders. They are the 'heart sink' patients [patients you don't want to see come through the door] that can't be cured, but can be kept out of hospital."
GP, general practice, metropolitan Queensland
One organisation indicated the MHNIP eligibility criteria were included on their MHNIP referral form.
Patient eligibility criteria in the Program Guidelines contain a range of factors, one of which is a hospital admission related to their mental health. Case study findings from patients interviewed in relation to hospital admissions found that over 60% had been admitted for their mental health illness at some time in their past treatment history. This is discussed further in section 5.6.
Detailed finding #15: the majority of medical practitioners select patients to participate in the MHNIP based on the criteria specified in the Program Guidelines.
There were signs that the level of mental illness that eligible medical practitioners consider severe and persistent varies across services. Section 5.10, Compliance Controls examines this evidence.
5.4.3 Care plans
The program guidelines contain the following requirement for care plans:"In collaboration with the mental health nurse, a GP Mental Health Care Plan must be developed by general practitioners or an equivalent plan must be developed by psychiatrists."
and
"The steps in preparing a GP Mental Health Care Plan are the same as those defined in Item 2710 of the Medicare Benefits Schedule for GP Mental Health care items."
The evaluation reviewed a sample of eleven care plans from five case study sites. This was not a formal audit of the care planning process, but a high level review of whether organisations were developing and using the GP Mental Health Care Plan (MBS Item 2710) as required by the Program Guidelines. Key findings were:
- none of the care plans demonstrated compliance against all specified criteria for MBS item 2710;
- all care plans included a record of medications;
- five of eleven met the criteria for patient agreement;
- two of the eleven care plans did not have mental health assessments provided;
- four assessments either did not have a patient signature or there was no place for this on the care plan;
- four of the eleven conducted a mental state examination;
- none contained evidence of the use of any formal outcome measure;
- one addressed risk assessment/ crisis planning/suicide risk;
- half of the care plans had identified goals (of varying quality, for example some had just one, word such as 'maintenance');and
- there was substantial variation in the reporting of the roles and responsibilities for the mental health nurse and the medical practitioner in the mental health care plan. The level of specificity was largely site dependent as there was no template document.
Detailed finding #16: there was evidence that MHNIP organisations are completing GP mental health care plans for patients. However, there is also evidence that not all plans are completed in a way that conforms with all the requirements of the MBS item.Top of page
5.4.4 MHNIP treatment duration
The length of time over which MHNIP patients received treatment was not specifically addressed during the evaluation. Analysis of DHS data should be able to determine the treatment duration using the patient unique identifier, although this could not be performed during the project as there were concerns over the accuracy of DHS patient level data.A small amount of anecdotal evidence was obtained during case study interviews with MHNIP patients and mental health nurses. Patients interviewed generally talked about their experiences over the past 12 to 18 months.
Mental health nurses described the patient treatment journey, indicating that initially contact was frequent and face-to-face, say weekly or fortnightly. As the patient's condition improved, the frequency of visits reduced, often to monthly and supported by telephone contact as needed. Towards the end of the patient's support under MHNIP treatment, the frequency was 3-monthly plus supported by telephone contact. It was also noted that patients often fluctuate along this pathway, it was not a steady reduction in contact frequency. By the time the patient was ready to exit, between 18 months and two years could have elapsed. This varied case by case.
Detailed finding #17: there was anecdotal evidence that MHNIP patients received treatment over a period between 12 to 24 months.Top of page