Mental Health Nurse Incentive Program: case studies project report
Client surveyA total of 57 people returned a client survey from the five services who agreed to distribute them. Of these, only one person chose the on-line option, with the remainder completing the written survey. A breakdown of responses by service is at table 3, and shows a marked gender bias with 44 (77%) female respondents. This is not reflective of the people using the MHNIP overall, as can be seen from individual service data, and from the Medicare data. Of the respondents, four people self identified as Indigenous, and of these one was male. All people responding to the survey identified English as their first language.
This survey cannot be considered a representative sample of clients using the MHNIP. However, the results do give some indication about the experiences of people who used the service.
Figure 1 identifies that over half (32) of the people who responded to the survey were aged over 40, and a further third (16) were aged between 26 and 40 years. Only nine people responding to the survey were aged less than 25 years.
Most people (79%) first heard about the MHNIP through their GP, while the remainder heard about the program through a friend or family member. Most people (61%) waited between one and four weeks to see the nurse, and only 12% had to wait more than a month for an appointment.
It was hypothesised that the convenience and lack of stigma associated with a service located in a medical practice would be a significant factor in whether people would be willing to see a mental health nurse. Clients were asked to nominate which factors helped them decide to use the program. They could choose more than one option. Table 4 details that for this sample of service users, the location was a factor for almost half (46%), giving only limited support to the notion that location is a significant feature of service usage. The most common response to this item was the doctor's referral (80%) helped with the decision to engage with a mental health nurse, while 54% cited their willingness to make personal changes.
Of this client sample, fifty-four clients (95%) consulted with the nurse on their own, while three were accompanied by a family member. A further six clients indicated that they sometimes see the nurse with a family member or carer. The majority of people (66%) consult the nurse at their own doctor's clinic, 17% have received a home visit, and ten people, from this sample, consult the nurse at another doctor's clinic. In total, 47 clients (82%) reported that they have a treatment plan, two people indicated they did not have a plan and another eight were not sure. A total of fifty-three people (93%) indicated that they are involved in making decisions about their treatment.Top of page
"... just thank you for being there. (Without the nurse) I might not be alive now."
Clients were asked to provide information about the type of support they were receiving from their mental health nurse. These options were based on the type of support that might be provided to people who meet the criteria for the MHNIP, that is, people with a severe mental health disorder who are significantly disabled by their disorder, and who are at risk of hospitalisation. Respondents were able to nominate as many options as applicable. Table 5 identifies that approximately four out of five people responding to the survey received psycho-education, three-quarters received assistance with recognising early warning signs and a total of 88% reported receiving assistance with dealing with everyday life issues. More than two thirds received education about their medication and more than half received support to take their medication regularly. More than half the sample also has assistance with their personal relationships and received help with other health issues.
Of those who nominated other types of support, one person was given help with finding other support services such as respite care and home help; one received assistance with budgeting; and one person with a disability received help with day to day "things". The remaining four people did not specify what other assistance they received.
While other evidence presented later in the report may suggest that the MHNIP is not always targeted to those at risk of hospitalisation, these responses suggest that the type of services provided under the MHNIP to this group are appropriate for the program target group.
Respondents were asked to indicate how long they had been receiving service from the nurse; 20% indicated less than three months, 32% indicated between 3 and 6 months. Of the remainder 14% had been seeing the nurse between 6 and 12 months, while 32% had been seeing the nurse for more than 12 months. Since these results only relate to this particular sample, no conclusions about average length of service provision can be drawn from this data. However, it is clear that for some people at least, this service is meeting their need for a long-term service without restrictions on the number of sessions. The snapshot data collection discussed below attempted to collect further data in relation to average length of service.
Another key feature of the MHNIP is the provision of service coordination for clients to access a range of health services and other community based services to reduce social isolation and increase community connectedness. The survey therefore, enquired about other services that people may have been referred to as part of their interaction with the nurse. People were asked to indicate any service(s) they had been referred to by the nurse. Table 6 identifies that only a small number people from this sample had been referred to another service. Those referrals that were made were predominantly to drug and alcohol services and social/activity groups.
In total, 11 people reported being referred to at least one additional service including; housing service (7); employment or education (6); Social activity group (11); Personal Helpers and Mentors (5); A Drug and Alcohol service (9); Psychologist (1) and Commonwealth Rehabilitation Service (1). Podiatry, dental services, psychiatry and a mindfulness group were also listed by at least one person.
An attempt was made to gauge client outcomes as a result of receiving a mental health nursing service through the MHNIP. The survey asked people to respond to a series of statements using a five point Likert Scale ranging from "Strongly Agree" through to "Strongly Disagree". The results obtained for these items are detailed in table 7, and provide a very positive picture of the impact this service has had on the lives of clients. Of the respondents, approximately four out of five people indicated that their mental health is much better now and they feel more in control of their lives; three-quarters said that their life has improved; and two thirds said they are now more motivated. Almost half of the sample reported improvements in their relationships, while a third said that they now have more friends. Only two people were non-committal about their satisfaction with the service and a further two people did not answer this question. However, fifty-three people (93%) indicated that they are satisfied with the service, with more than half of the sample answering "strongly agree". Since people who respond to the survey are still clients of the service it is likely that even more positive responses might result if a sample of discharged clients was surveyed.Top of page
Overall, people who responded to this survey were satisfied with the service they received. More than 80% of the sample reported that the service was provided in a way that meets their needs and another ten percent said that the service sometimes meets their needs. All but one person (98%) said they would recommend the service to others. People responding to the survey were given an opportunity to comment on what had been most helpful, and least helpful about the service, as well as any general comments they might have. The sample of comments below illustrates how positive people were about the service:
- I would no doubt have been admitted to hospital again if I did not seek help. This would have put more pressure and anxiety on me. Very happy with my nurse. She understands me.
- ... has been helping to keep me alive during a long period of being in crisis. He is always a positive in my negative life. Same person every time: a positive plan: worked with me, not telling me what to do: regular times in an unthreatening environment: my GP was able to be involved at all times.
- Having spent a lot of time doing community mental health stuff - shoved around from person to person this has been so much better and safer for me.
- No cost involved and able to see the nurse once a week continuously for over a year without any problems
- Mental health nurses do an amazing job and have helped my entire family.
- I need this service. I wish it could be weekly. I'd have more time when feeling better.
- He L.I.S.T.E.N.S 2 Me!!!
- From my personal point of view I think it is great. If anyone was thinking of expanding this service I think it would help a lot of people like myself.
Table 3: Client survey response
|Service||Number returned||Male||Female||Indigenous status|
|Longford Medical Services|
|Clare Medical Centre|
|Ballarat & District Aboriginal Corporation|
Figure 1: Client age - survey
Text version of Figure 1Figures in this description are approximate as they have been read from the graph.
- < 25 years - 9
- 26 to 40 years - 16
- > 40 years - 32
Table 4: Factors effecting service usageTable 4 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.
What helped you decide to see the nurse for your mental health issues?
- Doctor's referral - 80% (46)
- Family/friend - 19% (11)
- Convenient location - 46% (26)
- No service available before - 19% (11)
- I wanted to make personal changes in my life - 54% (31)
- Other - 8% (5)Top of page
Table 5: Type of support receivedTable 5 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.
Please tell us about the support you receive.
The nurse has helped me to:
- Understand my illness - 80% (46)
- Recognise my early warning signs - 74% (42)
- Understand my medication - 65% (37)
- Take my medication regularly - 54% (31)
- Deal with everyday life issues better - 88% (50)
- Improve my relationships - 61% (35)
- Manage other health issues - 56% (32)
- Other - 12% (7)
Table 6: ReferralsTable 6 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.
Have you been referred to other services?
- Housing program - 7 respondents
- Employment or education - 6 respondents
- Social/activity group - 11 respondents
- Personal helpers and mentors - 5 respondents
- Drug/alcohol service - 9 respondents
- Community mental health service - 6 respondents
- Other - 7 respondents
Table 7: Client outcomes
|Strongly agree||Agree||Neither agree nor disagree||Disagree||Strongly disagree||No response|
|My mental health is much better now|
|My life has improved|
|I have more hope for the future|
|I feel more in control of my life|
|I am more motivated to do things|
|My close relationships have improved|
|I have more friends|
|I am satisfied with the service|
Mary's storyMary (not her real name) is a 42 year old married woman with two children aged 18 and seven years. Mary is described as an excellent mother, has a supportive husband, and is committed to her treatment. Mary has a diagnosis of Borderline Personality Disorder with depressive features, Anxiety Disorder and Fibromyalgia. Mary has a long history of suicide attempts and frequent hospital admissions. At times in the past she would access her GP and the clinic nurse almost daily and required injections of pain medication three or four times per week. Mary has made a number of serious suicide attempts over the years. Mary's high levels of distress and serious suicidality resulted in psychiatric admissions on average for one in every four weeks. On occasion, Mary would be monitored in A&E overnight rather than admitted.
Mary's mental health issues are complicated by her physical health condition. The medication given to relieve the pain of her Fibromyalgia also has a depressive effect, exacerbating her mental health issues. Her suicide attempts have resulted in some liver damage. Mary had received various community-based mental health services in the past but they were not able to provide the intensity and continuity required. For a period of five years, Mary had also suffered from agoraphobia and was unable to leave the house alone. During this period, her husband took time off work to take her to appointments.
In the two years since she has been receiving a service from MHNIP, Mary has only been hospitalised twice and her use of intramuscular pain medication has been reduced to once every ten to twelve days. Mary continues to see her GP for short reviews on a weekly basis and only receives three days medication at a time in a Dose Administration Aid. Mary continues to have regular sessions with the nurse and her husband has received some support.
Mary gave permission for her story to be used because she wants funding for the MHNIP to continue.
Snapshot data collectionSince there was little comparable data about services available, it was decided to conduct a snapshot data collection across a one week period to capture simple data regarding all clients during that week. Both Clare and Geelong MHNIPs were able to produce some client data and chose not to participate in the snapshot collection. The remaining five services did collect data although for Ipswich, data was received from only two of the four nurses employed to deliver MHNIP services.
Data was received in relation to 85 clients across the five services. Of these, 63 (74%) were women, and 22 (26%) were men. This sample therefore is somewhat different from the overall numbers seen in the program since inception, as supplied by Medicare (April 2010). According to their data, the gender distribution is closer to 60% women, and 40% men.
The oldest people included in this sample were 70 years and the youngest was 15 years, showing the broad age range of people accessing the service. However, as depicted in figure 2, a total of 64 (75%) of these people accessing the service were aged between 35 and 64 years. A further 19 were aged 34 years and under, while only two were over 65 years.
Of this group, 29 (34%) had been hospitalised in the past for mental health issues, indicating that at least this number of clients met that particular eligibility criterion.
The co-occurrence of drug and alcohol issues with mental health issues is well recognised. This knowledge has not always impacted on practice in the mental health field, where screening for AOD issues is often not standard practice. In this sample, only 25% were recognised as having a concurrent AOD issue, which is considerably lower than might be expected.
During interviews with service providers, both managers and nurses, had indicated that the service is mainly being accessed by people with mood disorders, followed by those with anxiety and to a lesser extent by those with a personality disorder or a psychotic disorder. The data from this sample is shown in figure 3, and show that over 50% of the sample is classified as having a mood disorder, with approximately 20% presenting with an anxiety disorder. Given that these two disorders are considered to be "high" prevalence disorders, it would be expected that the greatest number of clients would present with these conditions.
The incidence of bi-polar disorder and other psychotic disorders in the general population is estimated at approximately 3%. At least 15% of people in this sample were diagnosed with one of these disorders. There is no way of knowing from this data what proportion of people in the other categories experienced significant impairment with their mental illness.
Figure 2: Client age – snapshot data
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Text version of Figure 2Figures in this description are approximate as they have been read from the graph.
Client age - snapshot data:
- 15-24 - 10
- 25-34 - 9
- 35-44 - 22
- 45-54 - 25
- 55-64 - 17
- 65-74 - 2
Figure 3: Primary diagnosis
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Text version of Figure 3Primary diagnosis:
- Mood disorder - 51%
- Anxiety disorder - 19%
- Personality disorder - 11%
- Psychotic disorder - 8%
- Bi-polar disorder - 7%
- Other - 5%
Bob's storyBob is a 26 year old single man diagnosed with Post Traumatic Stress Disorder. Bob started on antidepressant medication several weeks before seeing a MHNIP nurses. Bob had previously attended the local mental health service but no follow up occurred. Bob had recently been involved in an argument with his neighbours, as a result he was charged with threatening with a weapon. As a consequence, his employment was at risk.
Bob was referred by the GP with escalating anxiety symptoms and insomnia. Bob was quite guarded and difficult to engage, and assessment revealed he was experiencing psychotic symptoms including voices and paranoid thoughts. Bob has a past history of drug use, but not in the past two years. Bob had intermittently engaged with various mental health services throughout the state, but found his mistrust of people was unbearable to the point that he would move on, and not follow treatment.
An urgent assessment with the mental health team psychiatrist for a review of diagnosis and treatment was arranged by the nurse, who then attended the appointment with Bob. Daily contact was maintained with Bob, either face to face or via telephone to monitor his response to the medication. The nurse liaised with his family for support, education and awareness and supported Bob in arranging two weeks sick leave.
The nurse also advocated strongly for the mental health service to look beyond his drug use history. Subsequently Bob's diagnosis was changed to paranoid schizophrenia and anti- psychotic medication was commenced.
The nurse prepared reports for court; Bob's illness and his willingness to receive treatment were recognised and he was placed on probation with no mental health orders. He continues to receive treatment and has maintained his employment.
Sue's storySue is 59 years old, and lives with her husband and independent son. Sue was referred to the nurse for previously untreated anxiety which she had experienced since early adulthood. Sue presented with a range of anxiety symptoms including feeling frequently stressed and overwhelmed, racing thoughts, impaired concentration, sleep disturbance, muscle aches, fear and social isolation.
Sue did not want to take medication and attended weekly counselling sessions with her emotional wellbeing nurse instead. These sessions have focused on psycho- education, identifying triggers for worrying, learning strategies to help manage anxiety, problem analysis/solving strategies and development of her adaptive coping and self management skills. During these sessions Sue identified that she has difficulties expressing her emotions and needs. Sue and her husband now attend the nurse fortnightly to help Sue develop assertive communication skills.
Sue's anxiety symptoms are now minimal, with her initial HONOS score of L0 increased to 4. Sue has achieved her short-term goals of improved management of everyday tasks, and increased coping skills. Sue can now attend social functions and complete tasks such as supermarket shopping. Sue reports that her anxiety is no longer a burden for her, and her next goal is to travel interstate with her husband mid-year.