Evaluation of the mental health nurse incentive program
7 Overall findings and possible ways forward
Table of contents
7.1 Evaluation - summary of findings
Based on the commentary provided in the evaluation assessment we provide the following overview of our evaluation findings:- Appropriateness: MHNIP is providing support to a sizeable group in the community – people with severe and persistent mental health illness who are primarily reliant for their treatment on GPs and psychiatrists in the private sector (around 0.6% of the adult population). There are still large levels of unmet need from this group. The model of care involving clinical treatment and support by credentialed mental health nurses working with eligible medical practitioners received strong endorsement. This came from patients, carers and medical practitioners using the program, along with relevant peak bodies.
- Effectiveness: the evaluation found that MHNIP receiving treatment and support under the program benefitted from improved levels of care due to greater continuity of care, greater follow-up, timely access to support, and increased compliance with treatment plans. This was evidence of an overall reduction in average hospital admission rates while patients were being cared for, and reduced hospital lengths of stay where admissions did occur. There was also evidence that patients supported by MHNIP had increased levels of employment, at least in a voluntary capacity, and improved family and community connections. MHNIP has had a positive impact on medical practitioner workloads by increasing their time available to treat other patients and improve patient throughput.
- Efficiency: based on the de-identified patient data provided by case study organisations (N= 267 patients), the cost analysis suggests that savings on hospital admissions attributable to MHNIP were on average around $2,600 per patient per annum. This was roughly equivalent to the average direct subsidy levels of providing MHNIP, which ranged from an average of $2,674 for patients in metropolitan areas to $3,343 in non-metropolitan areas. 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.
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7.2 Possible ways forward
Observations on possible areas for enhancement of MHNIP are provided in table 7.1.Table 7.1 MHNIP design features – commentary and options to address program design issues
Table 7.1 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.Model of care
Current MHNIP design feature
- Target group: people in the community with a severe and persistent mental illness.
- Credentialed mental health nurses work closely with GPs and psychiatrists to provide coordinated clinical services. It should be noted that GPs and Psychiatrists are the primary care givers.
- The Program Guidelines outline functions that mental health nurses should undertake.
- There is no cap on the number of sessions a nurse has with a patient
- A nurse can be engaged to provide between one and ten sessions per week, per organisation, with an average nurse caseload of at least two individual services to patients per session.
Observations based on evaluation findings
- Medical practitioners, patients and carers have provided positive feedback that the program is meeting its objectives in keeping people with severe and persistent mental illness well.
See section 4.4.1, key finding 3 and key finding 4.
- A common patient pathway to access MHNIP services exists, however variations have been found, including triaging processes.
See section 5.4.1, section 4.4.2, detailed finding 3, and detailed finding 14.
Possible options for consideration, based on the evaluation findings
- The Program Guidelines could be further revised to clarify roles and responsibilities of eligible organisations and mental health nurses, particularly in relation to responsibilities in managing the triage process, services provided and clinical governance
Program participation
Current MHNIP design feature
- Eligible (ie registered) organisations, comprising self-selected:
- Private primary care services – general practices and private psychiatry practices
- Medicare Locals
- Divisions of General Practices
- Aboriginal and Torres Strait Islander Primary Health Care Services funded by the Australian Government through the Office for Aboriginal and Torres Strait Islander Health (OATSIH).
Observations based on evaluation findings
- There are varying degrees of program uptake across organisation types with GPs providing most MHNIP services and only a small number of Aboriginal and Torres Strait Islander Primary Health Services taking up the program. This self-selected, demand driven approach has resulted in inequitable service delivery (See Demand Management below) See section 4.4.2, section 4.6, key finding 5 and key finding 8.
Possible options for consideration, based on the evaluation findings
- Investigation into the causes of unmet demand would assist in determining the reasons for service inequity. Some factors to consider include socioeconomic trends in each geographic area, patient drivers and Commonwealth and state and territory services that are available for people with severe and persistent mental illness in areas of perceived unmet demand.
Funder
Current MHNIP design feature
- DoHA
Observations based on evaluation findings
- N/A
Possible options for consideration, based on the evaluation findings
- N/A
Purchaser
Current MHNIP design feature
- DoHA is the funder and purchaser (based on retrospective payment of claims in arrears).
- Purchasing intelligence: DHS reports.
Observations based on evaluation findings
- There is therefore limited control over program expenditure levels (other than the current cap on sessions).
- There is currently no mechanism to ensure equitable access to MHNIP services across geographies.
- Based on derived figures of population with severe and persistent mental illness, there is evidence that demand exceeds services currently available (See also detailed finding 8).
- As program is demand driven, supply side factors such as availability of nurses and perceived need by medical practitioners determine where services are provided. Due to this reason, service growth is not always linked to geographic areas where there was higher need for new services. See section 4.4.5, section 4.5, section 4.6 section 6.3, key finding 7 and key finding 8.
Possible options for consideration, based on the evaluation findings
- Consider ways to ensure any new service provision is targeted to regions of unmet demand rather than being driven by supply side factors.
- Ensure eligibility criteria on entrance and exit are clearly understood and complied with.
- Facilitate more formalised patient pathways between MHNIP and other appropriate services.
- Consider ways to manage program and regional expenditure levels.
Demand management
Current MHNIP design feature
- Nil, until application of the session cap in May 2012. Prior to this activity levels were driven by supply side factors:
- number of eligible providers; and
- number and availability of credentialed nurses.
Observations based on evaluation findings
- There is therefore limited control over program expenditure levels (other than the current cap on sessions).
- There is currently no mechanism to ensure equitable access to MHNIP services across geographies.
- Based on derived figures of population with severe and persistent mental illness, there is evidence that demand exceeds services currently available (See also detailed finding 8).
- As program is demand driven, supply side factors such as availability of nurses and perceived need by medical practitioners determine where services are provided. Due to this reason, service growth is not always linked to geographic areas where there was higher need for new services. See section 4.4.5, section 4.5, section 4.6 section 6.3, key finding 7 and key finding 8.
Possible options for consideration, based on the evaluation findings
- Consider ways to ensure any new service provision is targeted to regions of unmet demand rather than being driven by supply side factors.
- Ensure eligibility criteria on entrance and exit are clearly understood and complied with.
- Facilitate more formalised patient pathways between MHNIP and other appropriate services.
- Consider ways to manage program and regional expenditure levels.
Planning - practice level
Current MHNIP design feature
- Triaging at the practice level.
Observations based on evaluation findings
- Most medical practitioners from the evaluation were quite well informed of the types of mental health services that are available for their patients when deciding which Commonwealth Government mental health service program to refer their patients to. See section 4.4.4, key finding 6 and detailed finding 6.
- Level of acuity for patient entry into the program appears to vary. See section 4.4.4, section 5.4.2, section 5.5, section 5.10.1, detailed finding 15, detailed finding 25 and detailed finding 26.
Possible options for consideration, based on the evaluation findings
- Clinical governance processes at a regional level could be developed to promote greater uniformity in the level of acuity of patients entering and exiting MHNIP. Processes may need to be varied in accordance with access to other support for people with severe and persistent mental illness in the area (eg access to public mental health services varies by geographic region).
Planning - other levels (regional; national)
Current MHNIP design feature
- While nurse engagement and patient management is typically managed at the practice level, some eligible Medicare Locals triage at the sub-regional or regional level.
Observations based on evaluation findings
- Promotes greater uniformity of access across the geography See section 4.4.2, section 5.5 and detailed finding 18.
Possible options for consideration, based on the evaluation findings
- See above
Clinical governance - practice level
Current MHNIP design feature
- Some rules, as per the Program Guidelines, that are applicable to eligible organisations include the following:
- The mental health nurse delivers services in collaboration with the medical practitioner.
- The medical practitioner is required to practice formal protocols in managing patient mental health care, including the use of a GP Mental Health Treatment Plan, mental health nurse assessment of eligible patients at entry, every 90 days and when patient exit the program using the Health of the Nation Outcomes Scale, including the Child and Adolescent, Adult, and Older Person tools.
- Other activities: ad hoc (eg nurse clinical supervision is determined on a site basis between the medical professional and the nurse; professional development is at the nurse's discretion, other than what is required to maintain credentialed status).
Observations based on evaluation findings
- There is wide variability in clinical governance practices, including clinical supervision at a practice level. Quality could be improved if there was a more standardised approach. See section 5.5, appendix C and detailed finding 18.
Possible options for consideration, based on the evaluation findings
- Program Guidelines could be further revised to clarify expectations of mental health nurses and medical practitioners in service provision.
Clinical governance - other levels (regional; national)
Current MHNIP design feature
- The Program Guidelines provides program participants with guidance on patient, organisation and nurse eligibility criteria, administration of the program and guidelines that organisations registered to provide MHNIP should abide by.
Observations based on evaluation findings
- No formal clinical governance arrangements, however the Program Guidelines provide a range of requirements that relate to governance type activities. See section 5.5 and appendix C and detailed finding 18.
- Medical practitioners and nurses from the evaluation agree that the Program Guidelines are generally accessible; however there is scope to revise the Guidelines, in particular to allow for greater clarity in some areas including clearer description of reporting requirements and services that can be provided. See section 5.7.2 and detailed finding 20.
Possible options for consideration, based on the evaluation findings
- Develop a standardised approach to clinical governance at the regional and national level, including advice on:
- triage processes;
- case management processes;
- risk management;
- patient and carer complaint mechanisms; and
- identifying and supporting hard to reach population groups.
- The Program Guidelines could be further revised to clarify roles and responsibilities and reporting requirements