Evaluation of the mental health nurse incentive program

5.6 Patient outcomes

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The evaluation assessed the impact of MHNIP on patient outcomes in terms of changes in HoNOS measures, hospital admissions, employment activity participation, involvement in social and educational activities, and changes in the income security status of the carer. The case studies found that MHNIP generally had a very positive impact on patient outcomes.

5.6.1 Benefits for MHNIP patients
5.6.2 Changes in HoNOS scores
5.6.3 Reduced hospital admissions
5.6.4 Increased employment participation
5.6.5 Involvement in social and/or educational activities
5.6.6 Other changes

5.6.1 Benefits for MHNIP patients

There was strong support for the view that MHNIP has been beneficial for supporting patients with a severe and persistent mental illness. Table 5.9 shows over 96% of medical practitioners and 98% of mental health nurses who responded to the participant survey strongly agreed or agreed that MHNIP had contributed to improvements in care for people with severe mental illness.

"Benefits to patients have been decreased hospitalisations and decreased suicide attempts / ideation."
GP, Medicare Local, metropolitan Victoria
The top five benefits for patients through their involvement in MHNIP were reported as being:

• increased level of care / continuity of care / follow up;
• patients are able to access care in a much more timely manner;
• improved patient outcomes;
• increasing compliance with treatment plan, including medication compliance; and
• keeping patients out of hospital.

Table 5.10 shows the relative significance of these benefits as reported by medical practitioners in their survey responses.

"[MHNIP offers] clinical benefits to patients. There was also a positive impact on families. Patients are now accessing care they previously were not able to receive from their GP, they were falling through gaps."
GP, metropolitan general practice, Queensland
The evaluation report has previously observed that a key feature of the MHNIP design is the uncapped access of patients to support from the mental health nurse. Many of the patient benefits identified by medical practitioners are the enabled by that program design feature.

Key Finding 9: patients being supported under MHNIP are benefiting from improved levels of care as a result of greater continuity of care, greater follow-up, timely access to support and increased compliance with treatment plans.Top of page

Table 5.9: View of whether MHNIP has contributed to improvements in care for people with severe mental illness the views of participating medical practitioners and mental health nurses

Response	Medical practitioners No. of responses	Medical practitioners %	Mental health nurse No. of responses	Mental health nurse %
Strongly agree	137	71.7	221	85.7
Agree	46	24.1	33	12.8
Neither agree nor disagree	6	3.1	3	1.2
Disagree	1	0.5	1	0.4
Strongly disagree	1	0.5	0	0.0
Total	191	100	258	100

Source: survey of medical practitioners and mental health nurses

Table 5.10: Top five themes of the benefits of the MHNIP for patients - the views of participating medical practitioners

Response theme	No. of responses	% (n=191)
Increased level of care / continuity of care / follow up	135	70.7
Patients are able to access care in a much more timely manner	36	18.8
Improved patient outcomes	31	16.2
Increasing compliance with treatment plan, including medication compliance	25	13.1
Keeping patients out of hospital	22	11.5

Note: respondents feedback was often categorised into more than one theme, therefore the total number of responses is greater than the total sample number of respondents
Source: survey of medical practitioners

5.6.2 Changes in HoNOS scores

Mental health nurses at case study sites advised that patient HoNOS scores often fluctuate during the course of their treatment. Nevertheless, in their view HoNOS scores generally decreased between entry and exit from the program. This perception was tested in the cost analysis (detailed in chapter 6 and appendix E).

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. Table 5.11 shows 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. Personality disorders recorded the largest decrease in aggregate HoNOS scores (15.5 to 9.0; n=4), followed by mood disorders (14.2 to 10.6; n=52).

Key Finding 10: examination of a sample of MHNIP patients in the evaluation cost analysis showed a downward trend in their HoNOS scores, a measure of mental health and social functioning. This statistically validates qualitative perceptions that the treatment and support provided by mental health nurses improves the mental health and wellbeing of patients receiving support under the program.
The evaluation compared the HoNOS score of MHNIP program recipients with those patients receiving support from state and territory mental health services. We used the Australian Mental Health Outcomes and Classification Network web decision support tool to extract this information for three mental health care episode types: inpatient, ambulatory and residential care. Table 5.12 contains the mean total HoNOS for all mental health diagnoses, nationally for the adult population.

The HoNOS measures are lower than the MHNIP sample discussed above, further affirmation that the program is providing support to a group of patients with severe and persistent mental illness.

Key Finding 11: based on an examination of a sample of MHNIP patients, the HoNOS score of patients using state and territory mental health services were on average at similar levels to the scores of MHNIP patients, affirming that the program is providing support to people with serious levels of mental illness.Top of page

Table 5.11: HoNOS scores for patients included in MHNIP cost analysis^a

Disorder	HoNOS Number of Patients	HoNOS Mean score on entry	HoNOS Mean score at 12 moths	HoNOS Mean score change
Anxiety Disorders	11	12.4	9.3	3.1
Mood Disorders	52	14.2	10.6	3.6
Personality Disorders	4	15.5	9.0	6.5
Psychotic Disorders	19	11.8	9.5	2.3
Unknown	1	26.00	11.0	15.0
Total/mean	87	13.7	10.1	3.6

Source: HMA case study cost analysis
^a HMA collected similar data from a 464 patients at case study sites. This larger sample showed similar downward trends. They have not been reported here because they were not able to have the same level of data cleansing applied as for the cost analysis data subset. There were large data gaps for the reporting of HoNOS scores, which contributed to the small sample size.

Table 5.12: Mean HoNOS in state and territory mental health services, 2008-2011, compared to MHNIP experience

Collection setting	Mean HoNOS score on admission	Mean HoNOS score on discharge	Change in mean score
Inpatient	14.1	6.5	-7.6
Residential	11.7	10.2	-1.5
Ambulatory	11.7	7.8	-3.9
MHNIP evaluation cost analysis findings	13.7	10.1	-3.6

(Source: Australian Mental Health Outcomes and Classification Network, web decision support tool)

5.6.3 Reduced hospital admissions

Case study patients and representatives from MHNIP participating services reported that the program was effective in reducing unnecessary hospital admissions. Case study patients interviewed described a noticeable reduction in frequency of admission patterns since engaging with their mental health nurse. Table 5.13 shows over 60% of all case study patients interviewed (44 of 72 patients) had been admitted for their mental illness (at anytime in the past). Over the last 12 months prior to the conduct of the case studies, 25% of those patients with a previous admission (11 of 44 patients) had another mental health related hospital admission. This finding should be interpreted with caution as the figures for number of people who have had a hospital admission for their mental illness refer to occurrences that may have happened at any time of the person's life before participating in MHNIP.

"Yes, [I have been admitted to hospital in relation to my mental health illness] over 20 times. However, I have not been admitted over the last 12 months."
Patient, general practice, metropolitan Queensland

"Seeing the mental health nurse has stopped me from killing myself"
Patient, Medicare Local, metropolitan Victoria
Clinicians strongly felt that MHNIP had reduced unnecessary hospital admissions or readmission. Table 5.14 reveals over 91% of medical practitioners and 98% of mental health nurses either strongly agreed or agreed with this view.

"[MHNIP has been effective in] decreasing [hospital] admissions and length of stay if a patient was admitted."
Psychiatrist, private psychiatry practice , metropolitan NSW
Reference to the term unnecessary admission above acknowledges that in some cases MHNIP involvement lead to new hospital admissions. Such treatment was beneficial for the patient where it facilitated clinical stabilisation of a new medicine regimen or involved management of mental health issues and other comorbidities.

"M [the mental health nurse] made an appointment for me to see Dr A [the public hospital psychiatrist]. I wanted to take all my tablets"
Patient, AMS, regional NSW
The cost analysis assessment of MHNIP (see chapter 6 and attachment B) supported the perceptions of clinicians that MHNIP had a significant impact on admissions. The number of hospitalisations experienced by the sample of 267 cost analysis patients and their associated length of stay is summarised in table 5.15 below. Mood disorders, including depression and bipolar disorder, were the most prevalent in our patient sample with roughly two-thirds of all patients (66.3%; n=177) having this as their primary mental health diagnosis. Psychotic disorders, such as schizophrenia and schizoaffective disorder were the second most prevalent in our patient sample (14.2% n; n=38), closely followed by anxiety disorders (12.4%; n=33).
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Overall, the number of hospitalisations fell in the 12 months following entry to MHNIP compared to the 12 months prior to patients entering the program, from 34 admissions down to 30 admissions (-13.3%). This was not the case for mood disorders. While the total number of hospitalisations and total length of stay reduced for those patients whose primary mental health diagnosis was depression, a small number of patients with bipolar disorder experienced a significantly longer length of stay, resulting in a net increase in admissions for mood disorders from 18 prior to engagement in MHNIP to 20 admission post MHNIP involvement.

Psychotic disorders showed the most significant reduction in length of stay in acute settings, with six hospitalisations in the 12 months prior to joining MHNIP (length of stay = 756) and only one hospitalisation in the 12 months following entry to MHNIP (length of stay = 21).

For the same sample of patients, when they were admitted to hospital following their engagement in MHNIP there was a reduction in their total number of admission days by 58% and the average length of stay fell from 37.2 days to 17.7 days.

Key Finding 12: 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.

Key Finding 13: for the same sample of patients, when they were admitted to hospital following their engagement in MHNIP there was on average a reduction in their total number of admission days by 58% and the average length of stay fell from 37.2 days to 17.7 days.
Further analysis is required to explain why this reduction in the average length of stay occurred (this trend only became obvious during the data analysis phase of the evaluation). It may be that clinicians managing MHNIP patients admitted to hospital were more comfortable allowing a discharge when they knew the patient was returning to the care of a mental health nurse working under the supervision of a medical practitioner.

Table 5.13: Patient hospitalisation - experience of patients in case study site survey

Finding	No. of responses	% (n=72)
Has had a hospital admission for their mental health illness (at anytime)	44	61.1
Had an admission in last 12 months, related to their mental health illness	11	15.3

(Source: case study interviews with MHNIP patients)

Table 5.14: Assessment of whether MHNIP had reduced unnecessary hospital admissions and readmissions – view of medical practitioners and mental health nurses

Response	Medical practitioners No. of responses	Medical practitioners %	Mental health nurse No. of responses	Mental health nurse %
Strongly agree	108	56.8	208	80.6
Agree	66	34.7	47	18.2
Neither agree nor disagree	12	6.3	3	1.2
Disagree	3	1.6	0	0.0
Strongly disagree	1	0.5	0	0.0
Total	190	100	258	100

Source: survey of medical practitioners and mental health nurses

Table 5.15: Hospitalisations, length of stay and HoNOS scores 12 months prior to entry to MHNIP and 12 months after entry

Disorder	No. of Case Study Patients	No of hospitalisations 12 months prior	No of hospitalisations 12 months post MHNIP	No of hospitalisations % Change	Total length of stay 12 months prior	Total length of stay 12 months post MHNIP	Total length of stay % Change
Anxiety Disorders	33	9	8	-11.1	110	75	-31.8
Mood Disorders	177	18	20	10.0	384	426	10.9
Personality Disorders	9	1	1	0.0	16	10	-37.5
Psychotic Disorders	38	6	1	-83.3	756	21	-97.2
Other	7	0	0	0.0	0	0	0.0
Unknown	3	0	0	0.0	0	0	0.0
Totals	267	34	30	-13.3	1,266	532	-58.0
Average length of stay					37.2 days	17.7 days	-52.4

Source: HMA case study cost analysis

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5.6.4 Increased employment participation

The evaluation identified only minor improvements in employment participation of MHNIP patients. Whilst some MHNIP patients employed prior to treatment under MHNIP and remained employed, other patients who were unemployed remained so. Many of the patients interviewed during the case studies said that they were on a disability pension prior to their admission to the program and remained on that pension during their treatment. Table 5.16 demonstrates that almost 60% of case study patients reported no change in their employment status. Almost 20% reported finding employment and a further 12% became involved in volunteer work whilst receiving treatment under MHNIP. A small proportion also reported starting or returning to study.

"No, I'm still on worker's compensation. My goal is to go back to work, but maybe not the same place."
Patient, general practice, rural Queensland

"I started work 18 months ago. I would have lost this job too if not for the mental health nurse."
Patient, private psychiatry practice, metropolitan Queensland
Mental health nurses interviewed during the case studies suggested the reason for the small improvement in employment participation was due to several factors:

• moving from a disability pension to full-time employment was seen as a big step and if the patient relapsed, recommencing on a disability pension would be difficult especially during a time of relapse. Therefore, MHNIP patients often were not ready to change or only looked for part-time work at levels that would allow them to retain their disability pension status; and
  
  
• the severity of patient's mental illness could make it difficult to ever return to the workforce.

The medical practitioner survey sought views of the impact MHNIP had on employment participation. Medical practitioners were asked to estimate the proportion of patients employed prior to entry and on exit from MHNIP. Table 5.17 shows the results of the 60 respondents (31% of the sample) that provided both an entry and exit estimate. It suggests MHNIP has had a positive impact on employment participation.

Key Finding 14: there was some evidence of increased patient employment by MHNIP patients.
The evidence above shows that some MHNIP patients had commenced volunteer work for various organisations, such as the local hospital. This activity allowed patients to explore working environments in relative safety which did not impact on their pension entitlements.

Detailed finding #19: There was evidence of increased participation in voluntary work by MHNIP patients.

Table 5.16: Change in employment of MHNIP case study patients

Category	No. of responses	% (n=72)
No change	42	58.3
Obtained full-time or part-time time work	14	19.4
Now volunteering	9	12.5
Started or returned to study	5	6.9
No response	4	5.6

Note: respondents feedback was often categorised into more than one theme, therefore the total number of responses is greater than the total sample number of respondents Source: case study interview of MHNIP patients.

Table 5.17 MHNIP impact on employment participation - the views of participating medical practitioners

Outcome	No. of responses	%
Improvement	43	71.7
Detriment	3	5.0
No change	14	23.3
Total	60	100

Source: medical practitioner survey

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5.6.5 Involvement in social and/or educational activities

A large proportion of both medical practitioners and mental health nurses (measured as strongly agreed or agreed that MHNIP had assisted people to feel well and connected with their community. Table 5.17 indicates that over 95% of medical practitioners and over 97% of mental health nurses shared this view.

"[MHNIP] gives patient's confidence that they have a connection - someone to trust and who is helping"
Psychiatrist, private psychiatry practice, metropolitan New South Wales

"[MHNIP] increases their capacity to function in the community, decreases their anxiety and gets them socially connected."
GP, Medicare Local, rural Victoria
During the case studies mental health nurses and patients consistently reported increased levels of involvement in social and educational activities resulting from MHNIP treatment and support. This included:

• attending community social programs, such as the Men's Sheds;
• becoming involved in other activities, such as a choir;
• returning to part-time or full-time studies, after a break and commencing new studies; and
• undertaking short education courses, such as computing.

Key Finding 15: MHNIP has encouraged and facilitated patient's increased involvement in social and educational activities.
Case study organisations often advised that some of the patients interviewed during the evaluation have progressed, demonstrated by their newly found capacity to sit in the room for discussion with an evaluation interviewer. Being able to gather their thoughts and articulate responses to questions was a demonstration their improved wellbeing as a result of MHNIP treatment and support.

Table 5.18: Impact of MHNIP in assisting people to feel well and connected with their community - the views of participating medical practitioners and mental health nurses

Response	Medical practitioners No. of responses	Medical practitioners %	Mental health nurse No. of responses	Mental health nurse %
Strongly agree	115	60.5	207	80.2
Agree	66	34.7	44	17.1
Neither agree nor disagree	5	2.6	4	1.6
Disagree	3	1.6	1	0.4
Strongly disagree	1	0.5	2	0.8
Total	190	100	258	100

(Source: survey of medical practitioners and mental health nurses)

5.6.6 Other changes

Impact on carers

The case study component of the evaluation interviewed a small sample of patients (n= 66) and, in some instances, their carers (n = 6). The questions sought to identify changes in the status of MHNIP patient's carers over time resulting from the treatment and support received by the patient. The results as shown in table 5.19 for patients with a carer (n=26). The majority reported no change. However, a small number reported significant positive impacts on their carers, namely them no longer requiring the same level of support for the patient, or being able to go back to work.

"My husband has been my carer for years, but due to the mental health nurse [and my improvement] he has been able to return to full-time work. I did not get out of bed in the first week that he returned to work. But look at me now, I am able to be here talking to you."
Patient, general practice, metropolitan Queensland
In addition, some mental health nurses said that the MHNIP involvement lead to appropriate support (e.g. connection with Carers Support groups) and care for their own mental health needs.

Key Finding 16: MHNIP has had positive flow on benefits to some carers of MHNIP patients.Top of page

Table 5.19: MHNIP impact on carer status – the views of case study patients

Status change	No. of responses	% (n=26)
No change	22	84.6
Carer no longer required	4	15.4
Carer increased work participation	2	7.7

(Note: respondents feedback was often categorised into more than one theme, therefore the total number of responses is greater than the total sample number of respondents
Source: case study patients)

Other impacts

Case studies sought to identify a range of other impacts on patients as a result of their mental health nurse interaction. A small sample of patients responded (n=35), which identified five other positive improvements. The three most common impacts are contained in table 5.20, which shows improved family interactions, reducing ED presentations and managing drug and alcohol issues being most prevalent. The other two minor improvements were finding appropriate housing and improved physical health.

Key Finding 17: MHNIP has had other positive impacts on patients, including improved family interactions and reductions in the number of emergency department presentations.

Table 5.20: Other impacts on MHNIP patients – the views of case study patients

Other improvements	No. of responses	% (n=35)
Improved family interactions	19	54.3
Reduced emergency department presentations	13	37.1
Managing drug and alcohol issues	8	22.9

Note: respondent's feedback was often categorised into more than one theme, therefore the total number of responses is greater than the total sample number of respondents
Source: case study patients

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