Mental Health Nurse Incentive Program: case studies project report
Areas of interestA number of areas of interest regarding the way that the MHNIP has been implemented in each locality were explored using an approach based primarily on qualitative methods of inquiry. The questions investigated included the following:
- What was the perceived need that motivated the introduction of the MHNIP?
- How has the role been interpreted and/or implemented in differing localities? What factors influenced this?
- What is the model of implementation?
- What have been the establishment challenges? What strategies have assisted with overcoming or minimising these?
- What relationships have been built and how?
- What successes has the program achieved? What has contributed to these?
- What are the ongoing challenges and what might assist with overcoming these?
- What are the opportunities for enhancement?
Sample selectionAs of February 2010, preliminary Medicare data1 reports a significant number of organisations have registered with the MHNIP since the inception of the program in July 2007. This group of organisations includes Divisions of General Practice, private hospitals, general practices, psychiatry practices, and Aboriginal primary health care services. A small number of new organisations signed up in February 2010, indicating a continuing interest in delivering this service. A total of 7,036 sessions were delivered in February 2010, with 120,651 sessions delivered since inception. This represents a total of 40,556 people receiving a service through the MHNIP, since inception. Approximately 40% of clients were males.
Prior to the commencement of the case study project, organisations registered to provide services under the MHNIP, were asked to indicate if they were willing to participate in the project. From the list of eighteen organisations that volunteered, a sample of seven organisations was chosen in consultation with the NACMH members. Details of the selected organisations are shown in Table 1. Selection was based on achieving a sample that included varying size of organisation, different auspice agencies and a range of geographic settings.
The size of the MHNIP service included in the final sample range from very small (one nurse supporting one practice) to large (seven nurses supporting 29 practices). Services were drawn from five states, ranging from major city locations (Geelong, Ipswich), through inner regional centres (Bathurst, Longford, Ballarat and Mackay) to an outer regional town (Clare). No services located in a remote setting offered to participate in the study.
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The sample included four organisation types, along with examples of both direct employment of nurses and shared employment arrangements. There are three examples of shared employment arrangements, two are between a Division of General Practice and the local state mental health service (Geelong and Ipswich), while the third is an arrangement between a private agency, that employs mental health nurses, and an Aboriginal Cooperative that delivers primary health care services (Ballarat).
Initially, two other organisations were included in the sample. Unfortunately, the nurse from one service resigned the week prior to the first contact. This service did not anticipate being able to replace the nurse within a short time period and they withdrew from the study. This withdrawal reduced the number of states represented from six to five, and resulted in no example used of a MHNIP implemented in a private hospital. Contact with another service revealed some anomalies within the registration process which made them unsuitable for the case study.
Table 1: Sample of registered organisations participating in case study project
|Service||State||Geographic location||Organisation type||Employment model||No of nurses||FTE||Practices supported|
|Longford Medical Services||Tasmania||RA 2 – Inner Regional||General practice||Direct employment|
|Clare Medical Centre||South Australia||RA 3 – Outer Regional||General practice||Direct employment|
|Bathurst||New South Wales||RA 2 – Inner Regional||Private psychiatrist||Direct employment|
|General Practice Association of Geelong*||Victoria||RA 1 – Major City||Division of GPs||Shared employment|
|Ipswich West Moreton DGP||Queensland||RA 1 – Major City||Division of GPs||Shared employment|
|Mackay DGP||Queensland||RA 2 – Inner Regional||Division of GPs||Direct employment|
|Ballarat & District Aboriginal Corporation||Victoria||RA 2 – Inner Regional||Aboriginal Primary Health Care||Shared employment|
Data collectionThe methodology utilised up to four separate data collection processes across the seven sites:
- An initial service survey
- Stakeholder consultation in each of the seven localities
- Client survey
- Snapshot data collection.
- Australian College of Mental Health Nurses
- Australian General Practice Network
- headspace – National Youth Mental Health Foundation.
A Case Study Template was developed to guide the investigation of each locality. This template was intended to capture the major features of the program in some depth while maintaining consistency across the different locations. This approach has also been used in reporting each of the case studies. Table 2 provides a summary of the areas investigated.
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Table 2: Case study templateTable 2 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.
Domains and areas to investigate:
- Commencement: Perceived need, establishment, time operational
- Auspice body: Type of organisation, governance arrangements
- Location of program: Region covered, population demographics
- Workforce: Employment model, size of program, capacity
- Service Model:
- Role of nurse(s); where they provide services, management, clinical support
- Implementation, evolution of program
- Partnerships: Care Coordination Strategies
- Clients and carers: Access; demographics, involvement in treatment plans, diagnosis/es, outcomes
- Service provision: Service Activity levels, outcomes, impact on demand
- Quality mechanisms:Clients, GPs, psychiatrists
- Program themes:
- Opportunities, issues
- Areas for improvements
Initial service surveyBaseline data from each service was collected using an electronic survey. This survey was designed to capture the key background information about the service prior to a site visit. This allowed the consultants to be well informed and prepared service providers for the type of information to be investigated in more depth at site visits and interviews. Services were also asked to provide copies of any background documentation such as demographic data, policies and procedures, and outcome data analysis. A copy of the service survey is in the appendices (see preliminary service survey).
Site visitsSite visits were arranged for each of the participating services. Depending on the size of the organisation, one or two consultants visited the service and met with relevant stakeholders over half to one and a half days. Informal interviews were held with managers, nurses, participating doctors (GPs and psychiatrists), mental health service staff (where shared employment relationships occurred), and some clients. Other stakeholders such as community based mental health services and Divisions of General Practice were also interviewed where possible. For those not available on the day, follow up telephone interviews were utilised.
The case study template was used to guide the interviews.
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Client surveyAn assessment of the experience of clients was to be a key feature of the case study project, along with outcome measurement. It was expected that this information would be held by each service and could be incorporated into the case study without additional data collection. However, the initial service survey identified that not all services had collected and/or collated client data such as, general client satisfaction or outcome data including the HoNOS.
A client survey was designed and provided to each service with reply paid envelopes. Nurses were asked to distribute the survey to all clients seen in the past month. An on-line version of the survey was made available. The survey asked clients for some demographic information as well as aspects of their experience of the MHNIP including:
- information about gender, age, Aboriginality and language spoken
- information about their referral, including how they found out about the service, how long they waited to see the nurse, length of service, and what helped them decide to use the service
- service provision, including where they see the nurse, who with, treatment planning and type of service
- service coordination and referrals to other supports
- personal outcomes, including what changes have occurred for them as a result of seeing the nurse, and whether they would recommend the service to others.
In total, five out of seven services distributed the survey to clients seen in the previous month. The Ipswich and Geelong auspice bodies did not distribute the survey tool.
At the time of the site visit Ipswich was completing a formal evaluation of their MHNIP. This evaluation included a client survey. The agency decided that an additional survey could be a burden to clients. However, anecdotal information on clients. perceptions was provided by the Ipswich evaluators and is detailed in the Ipswich case study.
At Geelong, the partnership determined that the survey should be subjected to an ethics approval process before distribution. The timelines for the ethics process and this project did not align, hence the survey was not distributed to their clients.
Snapshot data collectionOnce the initial service surveys were returned and a number of site visits were conducted, it became apparent that there was very little quantitative data available about the program. Information was not readily available about aspects of the program, such as:
- the target group for each area
- service use per client
- outcomes that were being achieved.
In most cases, nurses. record information about interventions in case notes, at the client.s practice. Claim forms detailing the number of sessions provided and the client.s Medicare number are compiled by the registered organisation.
During the site visits, services estimated the demographics of the client group including, their main diagnosis and the average length of interventions.
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In order to gather some comparable data about clients receiving MHNIP services, services were asked to complete a snapshot data collection over a one week period. A tool was designed that allowed each nurse to complete some brief information about every client serviced within a one week period. This data included:
- how many clients were treated or contacted by the mental health nurse
- each client's age and gender
- whether they were seen face to face or contacted by telephone
- how long they had initially waited for a service
- primary diagnosis
- whether there were concurrent substance abuse issues.
- total number of sessions
- referrals to other community services.