Creating an integrated and responsive community acute care mental health service: to improve the quality of consumer outcomes in Hornsby Ku-ring-gai Mental Health

Summary

Aim

The overarching aim of this project is to have less fragmentation and increased alignment of processes to improve the patient journey for Hornsby Ku-ring-gai mental health community consumers.

There are three aims.

• By March 2019: 20% increase in consumer knowledge about continuity of care within the acute care team (ACT) survey
• By September 2019: 100% of mental health consumers entering the acute care team will have a clearly defined recovery pathway
• By September 2019: 20% increase in a positive consumer experience with the acute care team

Benefits

For consumers and carers

• One point of contact
• Improved pathway of care
• Improved communication around what the ACT does, and the consumer’s journey within this context.

For the acute care team staff

• Defined pathways and guidelines for consumers
• One point of contact for the consumer to provide consistency of care
• Improved skill in dealing with crisis customer service.

For community and inpatient teams

• Improved access to refer consumers to the acute care team
• Improved customer service
• One point of contact for the referring clinician.

For general practitioners, police, ambulance and non-government organisations

• Improved understanding of what the acute care team does
• Forums to be developed to support increased communication.

Background

The ACT is part of the wider Hornsby Ku-ring-gai Health Service community mental health team. It is a multidisciplinary staffed mental health community team comprising of psychiatrists, registered nurses, social workers, occupational therapists, psychologists and administrative roles.

Together, their role is to manage all community based acute presentations to the services, by providing:

• short term interventions to assist consumers to cope with the crisis or exacerbation of their illness
• consumer support when requiring follow-up on discharge from hospital
• after-hours services to the Hornsby child, adolescent and family team
• longer term care co-ordination for adults seriously affected by a mental illness.

The ACT is part of five community services:

• older persons mental health service
• assertive outreach team
• early psychosis intervention service
• Wahroonga rehabilitation service
• Hornsby Ku-ring-gai mental health service.

Hornsby Ku-ring-gai mental health service also has three inpatient units:

• psychiatric emergency care centre – 4 beds
• mental health intensive care unit – 12 beds
• adult mental health unit – 35 beds.

N.B. The consumer peer network is integrated into all inpatient and community teams.

The challenge is that while community and inpatient units employ 59.8 full time equivalent staff, need is still increasing.  In 2016/17 the service has seen community recorded activities rise to 95,190 occasions of service.

This increase has highlighted the following requirements:

• increasing need for community services
• improved integration required on the transfer of care into different teams
• increasing need to maximise the staff and skill mix to be most suited to a complex consumer cohort.

These increased care requirements highlight current operational risks and the risk of reduced quality in consumer outcomes. For example, adverse event data from Hornsby Ku-ring-gai mental health service has shown consumers can see an average of five clinicians, which results in a fragmented patient journey and the impact this can bring.

Theoretically, mental health community services should provide an integrated, comprehensive recovery service for consumers. In reality, there is a historical practice of services operating in silos which are not aligned to contemporary practice.  As a result, each of the community teams function independently which can result in a fragmented consumer journey.

Significant changes to funding models in mental health can impact on this journey, such as:

• the introduction of activity based funding
• the National Disability Insurance Scheme
• increased emergency department presentations.

Given the forecasted population growth across the Northern Sydney Local Health District (NSLHD), NSLHD mental health service delivery can no longer maintain the current status.

This clinical redesign project will address this by focusing on the ACT model of care, with the goal of having mental health consumers integrated across all mental health community services in the Hornsby Ku-ring-gai area.

Implementation

Solution 1 – Revised model of care, with a split of the team between crisis and case management roles

This intervention began in October 2018, where a new model of care was completed in consultation with key stakeholders. The acute care team will also undergo a restructure process through workforce services, and the restructure document has been completed as of April 2019, and is awaiting sign off from the Mental Health District. From there, official staff consultation will begin, with the view to implement the new model by June 2019.

Solution 2 – Acute care team packages

Identified packages or pathways have been completed for staff (internally and externally to refer to):

• clozapine pathway
• new admission pathway
• short term brief intervention pathway
• medium term or brief intervention pathway
• step down care pathway community appointments.

The pathways have an attached timeline to improve flow through the service. These pathways have been incorporated into the staff orientation manual, and they will go live once the model of care is endorsed.

Solution 3 – Consumer information brochures

Brochures have been designed and developed by staff on the acute care team to provide consumers with information about the acute care team and the timeline for the pathway they are on. Consumer peer workers also provided input in this process.

Information packs, including the brochure, have been given to new service consumers since February 2019. Carer packs have also been developed.

Solution 4 - Staff wellness program

Part of a positive consumer experience involves looking after staff who work with high risk consumers. To support this, the acute care team began meditating twice a week from March 2019 onwards. On average five staff attend each session.

Group external clinical supervision is also included for staff support, with bi monthly sessions starting in March 2019, although it is not mandatory that staff are rostered to attend. Three additional education sessions are also allocated each year, with the first session in May 2019 to focus on consumer customer service for crisis teams. To ensure sustainability, ownership of this program has been allocated to a senior team member as part of their portfolio.

Solution 5 – Introduction of interagency forums

Consumers have identified a lack of relevant recovery focussed groups. To address this, an introduction of interagency forums with non-government organisations will be the last intervention, planned for implementation in October 2019.

Status

Implementation - The initiative is ready for implementation, is currently being implemented, piloted or tested.

Dates

The project started in September 2018 and is due for completion in October 2019.

Implementation sites

• Hornsby Ku-ring-gai mental health acute care team
• Mental Health Drug & Alcohol
• Northern Sydney Local Health District

Partnerships

Centre for Healthcare Redesign

Evaluation

Evaluation targets include the following.

• By March 2019: there has been a 20% increase in consumer knowledge about continuity of care within the ACT as defined by the Your Experience of Service patient survey, and during the follow up telephone survey completed by the consumer peer worker.
• By April 2019: The wellness program will be evaluated by a staff survey.
• By September 2019: the goal is for 100% of mental health consumers entering services run by the acute care team to have a clearly defined recovery pathway. Another goal is for a 20% increase in a positive consumer experience with the acute care team. These outcomes will be evaluated by the Your Experience of Service patient survey and telephone follow up surveys.

Lessons learnt

• Project sponsorship is key: given external factors can temporarily delay interventions. The executive sponsor assisted in overcoming these challenges.
• Communication is key: with regular updates being essential for key stakeholder engagement and in regards to interventions. It is also important to stick to the communication plan.
• Keep a risks and issues log: this helped to prepare for any challenges faced.

Contact

Melanie Perry
Quality & Risk Manager
Hornsby Ku-ring-gai Mental Health Service
Northern Sydney Local Health District
Phone: 02 9477 9294
melanie.perry@health.nsw.gov.au