This assessment task covers learning outcomes 3 and 4:
• Demonstrate safe, interprofessional and therapeutic practice when planning health care for people with mental health issues and their carers;
• Utilise critical reflection and self-reflexivity to enhance clinical practice.
Task
A consumer from a vulnerable population has been referred to you, in your role as a mental health professional, for case management. This consumer has a complex mental illness profile, including comorbidity, and is currently in your local acute inpatient unit.
Part 1 (500 words)
Choose the vulnerable population and the particular case study that you want to focus on. Research this area and create a case presentation of a client.
Your case presentation should include the following:
• At least one major DSM-V psychiatric diagnosis.
• At least one environmental and social issue, along with a description of this.
• A description of the consumer’s social context, including family and carer involvement.
• Identification of a substance use issue, in addition to the mental illness that you have identified.
Part 2 (1000 words)
Due to the complexity of the consumer’s situation, the inpatient unit has requested your input, as a mental health practitioner, as to how they should best proceed with treatment whilst they are managing the consumer’s care. Provide a list of recommendations for the inpatient unit to use in the treatment plan. Your list should include:
• Any cultural considerations relevant to treatment of the client;
• Any psychosocial considerations that may be necessary when making decisions around pharmaceutical or therapeutic interventions;
• Any issues that need to be addressed prior to discharge and suggestions for how they could be addressed.
You should also identify:
• Any key family members or carers who should be included in decision making and any interventions they may need.
• Any other factors that the inpatient unit may need to consider in the treatment of this consumer.
Part 3 (500 words)
The consumer is approaching discharge. Create a care plan for this consumer (see Module 4 (3) for an example of one type of care plan format). With reference to the evidence-based literature, provide a rationale for your decision making in relation to this plan’s creation.
A note about this section:
Referencing
Use chapters in your text books that describe specific mental conditions to ensure your clinical health interventions are evidence-based.
You must use the APA referencing system. Follow
3. Early intervention, illness management and recovery
When vulnerable individuals succumb to mental health issues, what are the principles, practical implications and challenges associated with providing care for them? Are there ‘one size fits all’ solutions? What happens at different stages of mental illness? How does the consumer’s context and environment influence diagnosis, treatment and outcomes?
• 1. LISTEN to this discussion between Dr Sally Hunter and Dr Mary Ditton about the complexities of interventionURL
• 2. NOW LISTEN to some further points about medication for consumers with mental illnessURL
• 3. Principles of early interventionPage
• READ & REFLECT: Guiding principles of interventionForum
• EVALUATE: Measure of a mental health serviceForum
• 4. Putting principles into practicePage
• 5. The first step: assessmentPage
• 6. Managing complex mental disordersPage
• 7. Crisis management: involuntary interventionPage
• 8. Medication and ethics of carePage
• 9. Managing comorbidity and complex casesPage
• 10. Planning care for diverse consumersPage
3. READ Australia’s National Preventative Health strategy
This strategy is worthwhile for you to read, especially considering the impact alcohol has on so many aspects of individual, community and family life, for example: violence, injury, depression etc.
Australia: The healthiest country by 2020
(National Preventative Health Taskforce, 30 June 2009)
In 2010 the Federal Government responded to this taskforce report in the document Taking Preventative Action: A Response to Australia: The Healthiest Nation by 2020.
The Taskforce identified seven strategic directions underpinning the effective implementation of health promotion and preventative action, which are:
1. shared responsibility – partnerships at all levels of government, industry, business, unions, the non-government sector, research institutions and communities;
2. act early and throughout life – working with individuals, families and communities;
3. engage communities – act and engage people where they live, work and play;
4. influence markets and develop connected and coherent policies – for example the use of fiscal strategies to complement other arms of action;
5. reduce inequity – by targeting disadvantage;
6. Indigenous Australians – contribute to ‘Close the Gap;’ and
7. refocus primary health care towards prevention.
These principles apply equally to physical health and mental health promotion programs.
FURTHER READING: Meadows et al (2012) Chapter 4 Delivering Mental Health Care – provides further background and understanding of mental health care delivery systems and processes
Last modified: Wednesday, 25 February 2015, 11:54 AM
2. Mental illness prevention
Is it possible to prevent mental illness from developing or escalating in different individuals or populations? What are the strategies and approaches which serve to maximize mental wellbeing and minimize the risks of succumbing to mental illness for vulnerable consumers?
• 1. Social determinants of health: REVIEWPage
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1. Social determinants of health: REVIEW
Understanding the social determinants of health: a little revision
Let us briefly revisit the diagram by Turrell and Mathers (2000, p. 436) introduced in an earlier module, which shows the factors influencing mental health:
Source: Turrell & Mathers (2000a, p. 436) in Carson, B., Dunbar, T. and Chenhall, P.(2007). Social Determinants of Indigenous Health. Crows Nest, Sydney: Allen & Unwin.
It is important to note that this representation implies a composite view of health, and there has been much theoretical change in our view of health, health promotion and public health over the last forty years to arrive at this understanding.
Keleher and MacDougall (2009) in the first three chapters of their book Understanding health: A determinants approach provide a good overview of the evolution of the social model of health.
The social model of health
The social model of health complements the biological view of health that was consistent with the medical model and the functionalist perspective dominant in medicine and health services until recently.
Not only does the social model of health incorporate the notion that an individual’s health status is influenced by his/her genes and biological substrate but also that this biological substrate is influenced by social factors structurally determined in the communities in which we live. For example, global trade influences national economy, which influences employment, health services, education, community networks, family relationships and so on, impacting eventually on the health and wellbeing of the individual.
Starting with the Alma-Ata Charter on Primary Health Care in 1978 and the Ottawa Charter in 1986 there have been successive declarations by the World Health Organisation about the importance of changing social factors in order to improve the health and wellbeing of individuals. (You are encouraged to source and read more information about Alma Ata, the Ottawa Charter and other WHO conferences targeting global public health reform.)
The rationale for this is that if the arrangements in society change so that an individual can more easily make better choices for health, then the individual will make these better choices. For example, if government policies are more inclusive of diversity, then governments will try to develop services that accommodate difference, thus, for example, developing education and health policies that are more suitable for indigenous populations.
The figure from the Commission of Social Determinants of Health in Keleher and MacDougall (2009, p. 52) is another diagram similar to that presented to you in Module 1, but in this one Intermediary Determinants of Health are also mentioned.
The essential messages from these diagrams and readings that you need to recognise are:
• Health is a multidimensional concept incorporating a social model that impacts on a biological substrate;
• Individual and population health can be influenced by society factors;
• The importance of ‘difference’ to health status and access to health services;
• A multidimensional view of health means that there are opportunities to improve health and wellbeing for individuals and populations and these opportunities may be at a distance from the individual;
• The evolution of health rights and consumerism as forces in health services;
• The model expands the importance of social interventions in health and mental health services;
• Those people lower in the social gradient (lower income, less education, fewer social relationships etc) have the poorest health.
•
• FURTHER READING: Meadows et al (2012) Chapter 9 Mental Disorders in Australia considers interesting information regarding access to mental health services.
Last modified: Wednesday, 25 February 2015, 11:59 AM
• 2. Preventing mental health issuesPage
2. Preventing mental health issues
Health promotion, as a means of achieving ‘Health for all’, is seen as a process of enabling people to increase control over, and improve, their health. Because of the composite view of health mentioned above, there exists a continuum of health promotion approaches, as represented in this diagram from Talbot and Verrinder (2005, p. 35):
Some health promotion approaches target whole populations and have a community focus (for example, drink driving public health initiatives), whereas other approaches (for example, increasing the tax on Alcopops) have a regulatory and economic focus (in this case, to make drinking alcohol more expensive and therefore inhibitory).
Information about bowel and prostate cancer aims to increase individuals’ knowledge about health and changes in health so that the individual can make more beneficial decisions about his or her health-seeking behaviour.
Screening services for breast cancer, for example, are the application of the medical model to the individual to improve outcomes by early detection of cancer and therefore early intervention with treatment.
Keleher and MacDougall (2009, p. 54-57) discussed the five key determinants of health:
• Class and socio-economic gradient
• Early childhood development
• Poverty deprivation and social exclusion
• Health literacy
• Gender
When we consider these key determinants of health, many groups of people are disadvantaged structurally in relation to several of these determinants: for example, indigenous people in Australia, new arrivals to Australia, gay and lesbian people, foster children, people with disabilities, people who cannot speak English, second generation migrants, people of various occupations (e.g. police officers, undertakers), poor people, ex-criminals etc, etc. In fact the degree of tolerance exercised in society towards ‘difference’ is sometimes very small, so it is not hard to feel an ‘outsider’. Sometimes people who are divorcing feel they are failures in society, and unemployed or people made redundant feel they do not have a ‘legitimate’ role. Housewives sometimes feel like second-class women – ‘not doing everything modern women should do’. Also at various times in the lifespan it is hard to feel part of society. The young and the elderly are sometimes outside the mainstream concerns of society.
Consequently, when trying to prevent mental health problems we are often working to improve income and education, to support families so that children receive love and stability in early childhood, to reduce poverty and improve social inclusiveness, to increase understanding of health and signs of ill health, to enhance accessibility to health services, and to remove gender-related discrimination.
Primary, secondary and tertiary prevention
In the text by Meadows, Singh and Grigg (2007, p. 33), Singh defines primary, secondary and tertiary prevention:
Primary prevention aims to reduce the incidence of new cases through intervention before the disorders occur. Health promotion programs to support vulnerable new mothers are primary prevention for the children in those households to assist the mothers to provide ‘good enough’ mothering during early childhood.
Secondary prevention aims to reduce the prevalence of disorders through early identification of problems with intervention before the disorder becomes severe. Health promotion programs that help families identify signs and symptoms of early drug taking behaviour in adolescents is secondary prevention assisting families to intervene with their children before the drug taking behaviour is entrenched.
Tertiary prevention aims to reduce the prevalence of the disorders by reducing their duration through treatment and prevention of relapse. Severe mental health conditions, for example schizophrenia and clinical depression, require active intervention and ongoing intervention to prevent relapse.
FURTHER READING: Meadows et al (2012) Page 56-59 explores "The Preventaative Model".
Last modified: Wednesday, 25 February 2015, 12:03 P
• 3. Managing stress and life/role transitionsPage
3. Managing stress and life/role transitions
What is risk?
Risk factors are characteristics associated with an increased probability of a particular event, usually an injury or illness occurring (Murray, Zentner & Samiezade-Yard 2001:53). Risk assessment is part of the process of weighing up health problems and trying to be effective and efficient with interventions to benefit the individual and community. The regulation of risk involves attempts to control risk by setting and enforcing behavioural and product standards.
According to the Australian Bureau of Statistics report on the Social Trends for Health: Risk Factors among Adults (2003), the risk factor responsible for the greatest disease burden in Australia is tobacco smoking. Another common risk is excessive alcohol consumption. Excess alcohol consumption is linked to some cancers, liver disease, pancreatitis, diabetes and epilepsy. Smoking and drinking together account for about 17% of all disease (Australian Institute Health Welfare 2000:146–148). The risk factors of smoking and excessive alcohol intake have been studied extensively.
Beck’s Risk Society (1992) offers fair warning about the deceptive simplicity of the concept of risk in modern society. According to Beck (1992:3) risk is an ‘intellectual and political web’ cast by modern industrial society, in terms of problems (or risks) for the individual. These risks for the individual are conveyed in scientific language that ignores social rationality. Risks seem to concentrate in society at the lower end of the socio-economic spectrum. For example, lower socio-economic groups or those who are less powerful consume more tobacco. Also in the workplace, the least well paid workers not only operate in more hazardous environments, their amenities (e.g. tea rooms, wash rooms, etc.) are usually more limited than workers who attract higher wages. Their opportunities to have a break from work and refresh themselves, as well as their opportunities to move to better work environments, are also constrained. Beck (1992:35) makes the point that ‘risks seem to strengthen, not abolish the class system’, on the other hand [the] ‘wealthy [i.e. those with high incomes, power and education] could purchase safety and freedom from risk’.
Lupton (1995:77–105), Nettleson (1996:37, 53) and Petersen and Lupton (1996:18–20) comment on the pervasiveness of risk in literature of health and lifestyles and the limited ability that people have to control the social circumstances of their lives. These authors agree with Beck that more advantaged people have more control over socio-economic, environmental, living and working conditions. Therefore concentrating on lifestyle factors only, rather than on cultural and socio-economic factors, may contribute to increasing health inequalities because advantaged people will gain doubly—from their own power base to control external factors influencing their health, and from the renewed push of society as a whole to enhance better lifestyle choices.
Stress
Stress is an imprecise term, but in spite of this it has a significant place in the literature that deals with work and health. Semmer (1996:53) defines it as denoting states of ‘tension’ that are experienced by the individual as aversive and may have psychological and/or physical components. ‘Psychological stress[es]’ according to Kaplan (1996:3–4), are ‘the socially derived conditioned and situated processes that stimulate any or all of the many manifestations of dysphoric affect falling under the rubic of subjective distress’. Stress conveys negative emotional states such as anxiety, frustration, anger and guilt and/or physiological states such as racing heart, sweaty hands, dry mouth and increased respirations. Stress has to do with the appraisal of threat and/or loss. This definition implies that stress has to do with anticipated or experienced thwarting of goals. Stressors are characteristics in the environment that tend to elicit these emotional states in a given population. Stress is influenced by various environmental, psychological and social factors, but it is uniquely perceived by the person and intensifies when environmental change or a threat occurs (internally or externally) to which the person must respond (Murray, Zentner & Samiezade-Yard 2001:257).
A certain degree of stimulation for people is considered positive and motivating. The pattern for stimulation/stress and performance is shown in the figure below. This figure shows that while too little stress can cause apathy, excessive stress leads to unhealthy states and poor performance.
Stress/stimulation and performance (Source: Peterson 1990:23)
Work is often a significant source of stress. Cooper (1998:1–2) states that there is a ‘mountain of research in the cognate area of occupational stress’ and has developed certain principles in considering the effects of various stressors (Cooper & Payne 1988; Cooper 1998). These are summarised by Murray Zentner and Samiezade-Yard (2001:258) thus:
• the primary response to a stressor is behavioural, and the physiological impact is secondary;
• the impact is cumulative;
• circumstances alter the impact or harm done by the stressor;
• people are remarkably adaptive;
• various psychological or social factors may ease or exacerbate the effects of the stressor;
• there are definite low points when stressors are poorly tolerated;
• conditioning is an important protector;
• responses throughout life are local and general—local responses attempt to wall off and control the stressor, whereas general responses are characterised by alarm and resistance and when body resistance is not maintained, the end stage is exhaustion.
Risk and workplace stress management
Theories of workplace stress management vary from individual approaches that support individuals’ coping abilities, to more integrated strategies. The basic difference in the two approaches is that, in the former approach the individual is responsible for employee health, whereas in the latter approach, there is a synergy between individual and collective responsibilities for employee health in the workplace. Integrated strategies target the organisational demands and stressors, together with stress responses in individuals. The basic beliefs behind these integrated strategies are elaborated by Quick, Quick and Nelson (1998:247) and include:
• the interdependence of individual health and organisational performance;
• managerial participation in employee health and organisational performance;
• non-acceptance of individual and organisational distress as inevitable;
• unique reactions of individuals and organisations to stress;
• the ever-changing nature of organisations.
Protective factors
Just as health promotion programs focus on promoting mental health, they also try to reduce risk and they also try to increase protective factors against mental illness.
Protective factors are those factors that increase a person’s ability to cope with stress in life. Common protective factors are:
• stable home and living environment;
• positive personal relationships;
• adequate income;
• suitable emergency supportive facilities;
• community cohesiveness;
• social capital
• community capacity etc.
In thinking about the prevention of mental health problems we have to understand risk, stress and protective factors that operate in the environment of the person. Keeping in mind the composite view of health, some of these risks, stresses and protective factors may be proximate and/or distal to the person involved so our interventions may be complex and varied.
Resource
Visit this Canadian website (Centre for Addiction and Mental Health) to learn more about protective factors against mental health problems for children and youth.
Last modified: Tuesday, 1 October 2013, 12:53 PM
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• 4. Overview: Evidence-based mental health promotion and early interventionPage
4. Overview: Evidence-based mental health promotion and early intervention
Mental health promotion
Health promotion programs to reduce risk in the context of mental health are summarised in the diagram adapted from the original of Mrazek and Haggerty (1994):
As you can see from earlier definitions of primary, secondary and tertiary prevention, health promotion programs can be developed to any level of prevention. It is important to understand the nature of the health problem that you are addressing and the characteristics of population you are targeting through the health promotion strategy. Some of these concepts are covered in the diagram above and please note the definition of Universal , Selective and Indicative health promotion programs with a preventive focus.
Mental health promotion programs can be targeted to different populations in a universal, selective or indicated way. Definitions for these methods are given in Meadows, Singh and Grigg (2007, p. 34). It is important to understand these distinctions.
An example of a universal mental health promotion program is provided by Swannell, Hand & Martin (2009): The Effects of a Universal Mental Health Promotion Programme on Depressive Symptoms and Other Difficulties in Year Eight High School Students in Queensland, Australia, School Mental Health Volume 1, Number 4 / December, 2009 P 229-239.
For an example of a selective mental health program, visit the site referred to in the previous section, the Centre for Addiction and Mental Health, and look at Best practice guidelines for mental health promotion programs: Children & Youth:
I am reproducing the guidelines from this web site here because they could not be improved.
Guidelines for mental health promotion programs
These 10 guidelines define best practices for mental health promotion interventions. They are based on mental health promotion principles that have been identified through critical analysis of literature reviews. The guidelines are not intended to be used as an evaluation tool, but rather to improve existing interventions or develop new interventions. Not all components will apply in all contexts, because the guidelines are based on ideal mental health promotion interventions. Health and social service providers will have to take into consideration their own level of resources and restrictions, given the overall mandate of their organization. They should apply what is relevant for their programming needs.
1. Address and modify risk and protective factors that indicate possible mental health concerns.
2. Intervene in multiple settings, with a focus on schools.
3. Focus on skill building, empowerment, self-efficacy and individual resilience, and respect.
4. Train non-professionals to establish caring and trusting relationships.
5. Involve multiple stakeholders.
6. Provide comprehensive support systems that focus on peer and parent-child relations, and academic performance.
7. Adopt multiple interventions.
8. Address opportunities for organizational change, policy development and advocacy.
9. Demonstrate a long-term commitment to program planning, development and evaluation.
10. Ensure that information and services provided are culturally appropriate, equitable and holistic.
An example of an indicated mental health promotion in young people is provided by WHO (2010: Mental Health Promotion in Young People – an Investment for the Future By: Eija Stengård and Kaija Appelqvist )
Evidence based mental health prevention
Mental health prevention must be based on:
• Sound knowledge of the individual and social problem at a practical and theoretical level.
• This involves awareness of the extent of the problem, in its biological, social, historical, economic, and political dimensions and the theoretical concepts involved in the problem.
• Sound knowledge of practical and theoretical methodological approaches to solving the problem.
• Multidisciplinary collaboration to manage complex risk.
• Sound knowledge of prior interventions with similar problems.
Principles of early intervention with mental health
Early intervention principles are based on the same concepts as the evidence-based mental health prevention that has just been discussed, with some additional considerations.
Case identification and early intervention means that the health professional must be sensitive to what is happening to the consumer and what he/she is saying. You must give the consumer sufficient time so that in a discussion or interview conducted professionally you gain an understanding of the problem. You are constantly assessing the risk that the consumer poses to himself/herself or others and the severity of mental health problem. By the end of the interview you should be able to determine whether the consumer should be treated in hospital or not and how urgent or not the consumer’s needs are. Do not hesitate to seek assistance in assessment from your colleagues and other health professionals. With a respectful approach consumers will usually be wiling to be guided by your advice.
This discussion about principles of early intervention with mental illness will be continued in the next section.
Last modified: Wednesday, 25 February 2015, 12:04 PM
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3. Early intervention, illness management and recovery
When vulnerable individuals succumb to mental health issues, what are the principles, practical implications and challenges associated with providing care for them? Are there ‘one size fits all’ solutions? What happens at different stages of mental illness? How does the consumer’s context and environment influence diagnosis, treatment and outcomes?
• 1. LISTEN to this discussion between Dr Sally Hunter and Dr Mary Ditton about the complexities of interventionURL
• 2. NOW LISTEN to some further points about medication for consumers with mental illnessURL
• 3. Principles of early interventionPage
• READ & REFLECT: Guiding principles of interventionForum
• EVALUATE: Measure of a mental health serviceForum
• 4. Putting principles into practicePage
4. Putting principles into practice
Of course, it is one thing to espouse the correct principles and another thing to put these into practice. Those of you who work in large systems may have come across attitudes that are a far cry from those discussed in the previous section. You may have come across examples of racism or stereotyping of consumers e.g an indigenous Australian who is treated poorly because they have a mental illness compounded by a drug addiction. We would encourage you to examine your own beliefs and prejudices and become more aware of the beliefs and prejudices of those that you work with. It is easy to be drawn into thinking and behaving in a negative way towards people suffering from mental illness.
Here are some of the attitudes that you may meet when working in mental health:
Drug addicts don’t help themselves, so why should we help them, when our resources are so limited?
People with mental illnesses are violent and dangerous when they don’t take their medication.
You should be able to snap out of depression.
People who don’t take their medication are a menace to society.
Some people with mental illnesses should be locked up permanently.
Addictions are a choice, not a mental illness.
If you have a mental illness, you don’t suffer as much as when you get physically sick.
The families and carers suffer more than the person with the mental illness.
It’s the families who cause the person to become mentally ill.
You can never recover fully from mental illness.
Check your assumptions!
There is a website that you can go to, in order to check your own knowledge of facts/myths in mental health. It is run by Mental Health America of Eastern Missouri. See how many out of ten you score:
http://www.mhaem.org/mental-health-illness-topics.html?task=article_view&article_id=35
The reason for asking you to assess your own attitudes to mental illness is to make you aware of your own prejudices and negative beliefs. We all have these, to a certain extent, depending on our personal and professional experiences.
Reflection… You might like to write a private list of all your beliefs about people with mental illness. Try to be honest about your feelings and own up to any prejudices that you may have. Think about whether these beliefs come from your personal experiences or your work environment.
Decide if any of these beliefs will get in the way when you are working with consumers suffering from a mental illness.
Talk to a trusted colleague about how you might change any problematic beliefs that you have, or any problematic behaviours that you see around you in your work environment.
READ: Meadows (2012) pp 27-30 discussing stigmatisation – consider your perspectives and attitudes
Last modified: Wednesday, 25 February 2015, 12:12 PM
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• 5. The first step: assessmentPage
5. The first step: assessment
Assessment as the first step towards appropriate intervention
The period of providing care, particularly in the acute phase of an illness is a complex puzzle which clinicians must piece together. Consumers don’t come with a single diagnosis or with issues that can be fixed in the same way as for the previous consumer. Every case is unique and requires clinicians to think critically about the situation and what can be realistically achieved. Assessment is the first stage of working through this puzzle and to offering the consumer appropriate care and therapeutic interventions.
Assessment is covered in detail in HSMH421 and you can refresh your knowledge of this topic before continuing if you wish by visiting the Revision Zone.
Revise Chapter 12 in your Meadows text.
It covers the Mental State Assessment and the HoHOS instrument in detail.
Risk assessment and management
In the front of every clinician’s mind should be management of the risks present in each individual case. This is not merely risk of harm to self and others, but also vulnerability to violence and exploitation, and risks to a person’s good reputation. In a majority of cases, risk can be managed by medication and psychosocial intervention; however there are times when a consumer is unable or unwilling to participate in treatment and therefore risk cannot be easily managed within community care (Meadows et al, 2012). One of the main purposes of assessment in relation to mental health interventions is to assess where the consumer will be treated: in hospital (as a voluntary or involuntary patient) or within the community. This will largely depend on the level of risk that they pose to themselves and to others and where they will receive the best possible treatment.
• 6. Managing complex mental disordersPage
6. Managing complex mental disorders
Whilst early intervention should be the goal of most acute service providers it is the reality that this is not always the case. Stigma and common misconceptions surrounding mental illness often result in consumers not accessing mental health services until episodes have reached a more severe level (Meadows et al, 2009). No matter when a consumer presents to services it is important that we view the consumer as sitting within a continuum of care, with an understanding that treatment involves several phases of care with the view to providing a recovery based service (Australian Health Ministers, 2003).
Generally individuals fit within a continuum in the following manner:
(Commonwealth Department of Health and Ageing, 2000)
The arrows in this diagram point both ways because it is not a linear process. Many consumers move in both directions from the community to inpatient acute care and then back to community based intervention and so on. Some stages of illness require acute care whereas others don’t. When working in a recovery-focused way, clinicians should always bear in mind that recovery is the main goal of intervention.
But what do we really mean by recovery?
Read
Read the relevant pages of your Meadows text about recovery and supporting recovery in Chapter 17
Reflect
What is your definition of recovery? How do you envisage your role in helping the consumer with their recovery process?
Recovery can be viewed as a journey through differing types of care (Meadows et al, 2012). It often starts with the mental health issue being diagnosed and care being offered to the consumer within the community, if at all possible.
If this is not sufficient, the consumer may receive acute care in hospital as an inpatient. Following a period of acute care, there needs to be a period of rehabilitation which may involve both inpatient and outpatient care. This is then followed up by community support, with a focus on relapse prevention.
It is important during all these stages that clinicians work closely within their treating teams and make clear the role they are playing in the recovery process. Clear consistent messages are important during the whole treatment process, as relapse prevention work towards the end is reliant on consistent messages throughout the treatment process.
Community based intervention
Assuming for a moment that the assessment stage suggests that care within the community is appropriate for the consumer, there are two main types of intervention that are possible:
• Therapy or the use of suitable focused psychological strategies
• Advocacy and social support
These two main types of intervention are conducted within the context of interdisciplinary collaboration and planning.
Therapy
When planning therapy it is important to consider the client in their entirety (Meadows et al, 2012). The following should be considered prior to planning any therapy with a consumer:
• Is the consumer willing to continue with therapy for the time required?
• What psychosocial issues may prevent therapy from succeeding? (eg. geographical isolation and low income preventing travel)
• Is the client sufficiently safe and secure in order to reduce stress to the point where therapy can succeed?
• Does your service have the resources to provide the therapy needed for the period it is required?
Quite often these issues create barriers to treatment and provide many clinicians with a very difficult decision: what do you provide to a client when the most obvious evidence-based intervention is not a viable option?
When therapy is unable to progress for one of these reasons, a mental health practitioner can do two things. First, they can work to mitigate risk and build rapport with the client. Rapport is often the greatest indicator of successful outcomes, more so than the type of therapy used (Hernandez et al, 2007). Mitigating risk, by addressing practical issues and improving the consumer’s day-to-day living arrangements, is an important intervention in its own right. It provides an increasingly safe environment for the consumer and helps to build a collaborative relationship, thereby laying the foundation for future therapies (Miller & Rollnick, 2002). Secondly, they can provide psychoeducation in order to improve the consumer’s insight, motivation, and commitment to therapy (Miller & Rollnick, 2002).
Advocacy
Advocacy plays an important role in the process of intervention. Depending on your role there are a number of ways in which advocacy on behalf of consumers and their families forms an integral part of intervening. There are number of ways in which this can occur (Meadows et al, 2012):
• Advocacy for clients experiencing discrimination as a result of their diagnosis in areas such as employment and housing. Quite often this form of advocacy involves assisting employers, landlords etc, to think creatively about how they do business and to educate them about misconceptions they may have about the inability of mental health consumers to undertake employment or tenancies.
• Advocacy for clients who are prevented from entering other services due to their mental health diagnosis. For example, older people with a mental health diagnosis have difficulty accessing aged care facilities due to the perceived level of care they require. Advocacy for equal rights to access other services is often key to successful placement of those with complex needs beyond a simply mental health diagnosis.
• Advocacy within the treating team for consideration of holistic approaches to care. Often it can be that the most prominent issue or aspect of a consumer’s presenting profile receives the most attention with more subtle yet equally important aspects (often psychosocial) receiving less attention. Depending on your discipline you may need to advocate for consideration of less recognised factors in care planning. For example, you may be advocating for extended stay on the grounds of housing difficulties that would undermine a consumer’s ability to continue treatment, whilst other members of the team may focus more on pharmaceutical treatment in the context of the inpatient unit without thought to how that will continue in the context of returning to an unstable home.
• Advocacy on behalf of families and carers. Family and carers are often responsible for providing treatment on a much more regular basis that the health professionals involved in care. Therefore it is often necessary to advocate on behalf of families and carers within the treating team, to ensure that plans made by the team take into consideration the attitudes and abilities of those who will be providing care long-term.
Interdisciplinary collaboration
Interdisciplinary collaboration and planning is essential in the ongoing treatment of consumers (Meadows et al, 2012). In NSW (other states have similar clinical documentation, please refer to local forms for equivalents) MHOAT forms provide a care planning and review structure that assists clinicians and teams to plan care for consumers (NSW Department of Health, 2008). It is essential that these forms be completed and reviewed on a regular basis. For inpatient units care planning and review must be done on a weekly basis, with more detailed reviews every 21 days. For community teams it must occur every 12 weeks. This process ensures treatment remains focused and takes into account changes in the consumer’s mental state and life circumstances.
Read
Chapters10, 14, 16 and 17 of your Meadows text.
• Chapter 10 covers the roles of the mental health nurse, the psychiatrist, the social worker, the OT, the psychologist, and the GP in the field of mental health.
• Chapter 14 covers case management and looks at the different roles for nurses, OTs, psychologists, social workers, psychiatrists and psychotherapists within case management. Each team needs a case manager to co-ordinate the roles of the various mental health practitioners. In a well functioning team, it is often difficult to tell the professional backgrounds of the various members of the team as they work together for the benefit of the consumer.
• Chapters 16 and 17 cover more detailed explanations of intervention and rehabilitation models.They demonstrate that rehabilitation is a wider concept than treatment, since it covers practical assistance with meeting basic human needs, employment and social skills training, as well as day-to-day living skills. Thus providing treatment is a much broader concept than simply providing therapy or drug treatment.
Extension
If you are interested in understanding the treatment options for various mental health disorders, you might like to read Chapter 18 onwards. Each chapter covers a different disorder eg. Chapter 18 covers personality disorders, Chapter 20 covers developmental disabilities and psychiatric disorders etc
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Last modified: Wednesday, 25 February 2015, 12:15 PM
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7. Crisis management: involuntary intervention
When a consumer is facing a crisis of some kind, it is necessary to intervene in terms of crisis intervention. When the consumer is experiencing a psychotic episode, or is a danger to themselves or to other people, this may necessitate involuntary hospitalisation.
There are a number of options available to clinicians who feel that involuntary intervention is necessary.
Conditions for involuntary intervention
• First and foremost in order to ethically apply coercive practices, a clinician should be satisfied that risks posed to a consumer or those around them cannot be remediated any other way.
• They also should be certain that the reason for this situation is directly related to cognitive impairment as a result of mental illness, disability, organic syndrome or brain trauma. That is to say, clinicians have no ethical grounds to treat consumers who have capacity to make informed choices as involuntary patients just because their choices are not considered to be appropriate by others. This could include choices such as sexuality, religious affiliation or drug and alcohol abuse (Attorney General of NSW, 2008).
Formal involuntary treatment is designed with a number of checks and balances to ensure the rights of consumers are upheld (NSW Minister for Health, 2007). This is in comparison to informal methods of coercion such as the common practice of holding people voluntarily with the promise that if they try to leave they will be scheduled. Whilst on the surface this is described as least restrictive care, what is actually happening is that a consumer is being coerced to stay without independent inquiry into the appropriateness of the involuntary treatment. Ethically this is a very dangerous practice and should be avoided. In other countries patients have successfully brought lawsuits against hospitals that engage in this practice.
Forms of involuntary treatment
The four major types of involuntary treatment are:
• Involuntary admission
• Community Treatment Orders
• Financial management orders and
• Guardianship orders.
The following descriptions are current for the state of NSW. There may be variations to this information depending on state law. Take time to investigate these orders and their implications in your state or territory.
admission is the process by which a consumer is kept against their will in a mental health facility. There are a number of different orders depending on the length of time that they are detained, and the level of assessment and treatment that has been completed. As a general rule, the longer a consumer has been (and is to be) detained, the higher the number on the order (e.g., S22 is a minor order compared to S33). Please refer to the NSW Mental Health Act 2007 for a complete explanation of Mental Health Act orders (NSW Minister for Health, 2007).
Orders of more than a week are generally made by either a magistrate or a tribunal. When presenting a case, clinicians must prove that there is significant risk posed to a consumer if they do not receive treatment and that a treatment plan that addresses these risks is in place. Community treatment orders also sit within state Mental Health Acts. These are orders that spell out not only the responsibilities of the consumer in terms of their ongoing care in the community, but also the responsibilities of the mental health team providing care. They will typically spell out the required medications, the frequency of appointments, and any other conditions that may be necessary to maintain mental health and wellbeing, such as abstinence from drugs and alcohol.
Diagram source: http://www.audit.vic.gov.au/publications/2002/20021017-Mental-Health-Services-for-People-in-Crisis.pdf
Community treatment orders
There are a number of things to consider when planning for community treatment orders:
• Are the conditions enforceable? That is, can you as case manager ensure that the consumer is complying? If the consumer is on oral medication three times per day, how will you make sure they are taking the medication? With some medications (such as Clopine or Lithium) blood levels can be taken to monitor compliance. In other cases it is necessary to consider medication administered fortnightly or monthly by a clinician who agrees to monitor compliance.
• Will you be prepared to breach someone if they fail to meet part of the community treatment order? If the therapist would not be willing to take the consumer back to hospital if they missed a therapy session, then this condition should not be included in the order.
• Does the client have a history of non-compliance? Tribunals will need to see evidence of non-compliance in the community, before they will authorize a community treatment order.
Guardianship orders (including financial management orders) are designed for people who do not have capacity to make informed decision regarding aspects of their lives. The following information is current in the state of NSW. If you are not practising within this jurisdiction, you should check your own state’s guardianship laws for any changes or major differences.
Guardianship orders for people with mental illness have been found to be just as beneficial for mental health consumers as community treatment orders, particularly in cases where consumers have complex Axis 4 diagnoses (Carney & Tait, 1997). In order to seek a guardianship order, clinicians must prove that the consumer lacks the capacity to make informed decisions and that there are significant decisions that need to be made in order to improve their health and wellbeing (Attorney General of NSW, 2008). For mental health consumers, common reasons for lack of capacity include:
• Delusional disorders
• Frontal lobe impairment leading to impulsivity
• Emotional disregulation leading to impulsivity
• Chronic psychiatric impairment
• Body dysmorphic syndromes
When applying for an order, it is important for clinicians to identify in which areas they wish to seek a substitute decision maker or guardian. The areas in which a substitute decision maker can be appointed are (Attorney General of NSW, 2008):
• Finances
• Accommodation
• Medical treatment and procedures (including dentistry)
• Access to services (such as home care, meals on wheels, psychiatric rehabilitation)
• Who is permitted to have contact with the consumer (normally used to protect consumers from exploitative and violent relationships)
It is also necessary to determine whether there is a family member or carer who is suitable and willing to undertake the guardianship role, or whether a public guardian must be appointed. One must also decide whether the appointed person will need to be given coercive powers in order to undertake this role or whether the client will be willing to abide by decisions voluntarily (Attorney General of NSW, 2008).
READ: Meadows et al (2012) pp 445-8 about CTO’s
Reflect
When discussing involuntary treatments we often forget that the process of obtaining an order involves both clinicians and consumers entering the legal system.
Hearings are set up as in a criminal court room, with the clinician on one side and the consumer (and sometimes a lawyer) on the other. The magistrate or tribunal is at the front and, at the discretion of the magistrate, family members and carers may or may not be allowed to attend.
• What impact do you think this has on the consumer and their relationship with their treating team?
• What messages do you think this sends to consumers about the nature of their situation?
• How could this process be differently approached to make it more consumer friendly?
8. Medication and ethics of care
Pharmaceutical interventions
Pharmaceutical interventions are a major part of work within the mental health system (Meadows et al, 2012). However as demonstrated throughout this unit, medication is used within a much larger context of care. When planning occurs around medications, it is important that decisions are made as a team.
The following factors should be taken into account when planning around pharmaceutical interventions:
• Can the consumer reasonably afford the medication being prescribed? Some medications used in psychiatry are only on the pharmaceutical benefits scheme for specific diagnoses, despite their more broad use. Clearly prescribing medications which are financially prohibitive will not assist consumers in compliance.
• Will the consumer be placed on a treatment order? If so, does the medication prescribed allow for monitoring?
• Does the consumer have a history of deliberate self-harm? If so, is the medication being prescribed likely to be used in a future suicide attempt? If this is a possibility then consideration might be given to clinician-administered injections or, if the drug must be taken orally, to arranging for a pharmacist to dispense only small amounts of medication at a time.
• Does the consumer have a history of substance misuse? If so, some thought must be given on avoiding medications which may cause dependency or increased potential for abuse, such as benzodiazepines and dexamphetamine.
Ethical practice when providing treatment is essential for a number of reasons. Most importantly, ethical practice ensures that consumers are treated respectfully and their best interests are maintained at all times (Meadows et al, 2012). Another reason why it is important that you understand and work by your profession’s code of ethics is that it provides protection for you as a worker. The consequences for people who do not adhere to prescribed codes of ethical conduct can be deregistration and, on occasion, expulsion from practice.
Whilst each discipline has its own set of ethics which you should all be familiar with, there are some ethical principles and considerations that all clinicians should be familiar with before providing treatment to consumers:
• Pharmaceutical company promotion. Pharmaceutical companies invest significant amounts of money into promotion of their products. This can range from branded stationery through to free dinners and clinician retreats. Whilst these promotions can be appealing, a clinician’s intervention should be evidence-based. Clinicians should avoid any perceived conflicts of interest by reducing their reliance on promotional products.
• Clinicians should always provide balanced information to consumers. It is tempting to gloss over the negative side effects of medications in order to encourage medication compliance. However, consumers should always be made aware of the negative side effects of treatment in order to make informed decisions about their care.
• When consumers are assessed as having capacity to make informed decisions, clinicians should be careful not to withhold information or manipulate consumers into making particular decisions based on the clinician’s beliefs about what should happen.
Reflect
Review your own profession’s code of professional ethics and think about issues about which you have a strong moral belief.
• How would you manage a situation in which your moral code and professional code differed?
• What would be an example of this situation for you?
READ: Meadows (2012) pp 47-49 discussing the Ethical Underpinnings of Health Care Delivery
Last modified: Wednesday, 25 February 2015, 12:20 PM
• 9. Managing comorbidity and complex casesPage
9. Managing comorbidity and complex cases
Mental health issues do not occur in isolation. Mental illness occurs within a context, and the level of complexity can often be overwhelming.
When managing cases of co-morbidity, it is important to begin with a thorough assessment of the consumer (Meadows et al, 2012).
When conducting this initial assessment it is important to paint a full picture of the consumer and their experiences in context. It is also important to get an appreciation of the relationship between different issues the consumer faces. For example, if a consumer has alcohol dependence and a problematic relationship with their partner, it is important to establish how the two are connected. Does the consumer drink to cope with the stress of the relationship, or does the consumer’s drinking cause the relationship breakdown? Once a fuller picture of the consumer is determined, it is then possible to begin to address each issue based on your greater understanding of the consumer’s situation as a whole.
Multiple agency involvement
When managing complex cases there is more often than not the need for more than one agency to be involved. When working with cases involving multiple agencies it is important to consider the following practical measures to ensure the best outcomes for consumers:
• Designate a lead agency: When providing collaborative interventions a lead agency or worker should be identified to perform coordination tasks such as convening case conferences and handling management of the overall treatment.
• Communication: The lead agency or worker should ensure that appropriate permissions are gained for agencies to share information regarding the consumer with other workers involved in providing care. This establishes a culture of openness and transparency and prevents consumers from shopping between workers for desired outcomes.
• Case conference: Before any treatment begins it is important to facilitate a case conference involving all concerned parties, including the consumer (although the consumer may be present for only a part of the meeting). During the conference, attention should be given to the following matters:
•
o Clearly defining roles and responsibilities of all parties.
o Outlining treatment goals.
o Establishing communication protocols.
o Developing a shared understanding of the consumer and the interventions needed.
o Determining time frames for intervention.
o Setting up review dates for further case conferences (Arkowitz et al, 2008).
Integrated care
One of the disadvantages of multiple agency involvement is that differences between agencies (for example, in areas such as underlying philosophy and staff skill levels) can often lead to consumers receiving mixed messages, which in turn can negatively impact on consumer outcomes (Arkowitz et al, 2008). The alternative is to provide integrated care: that is, that one agency works to meet all the major needs of the consumer simultaneously. Whilst this method of working is not always possible, it does have these advantages (Arkowitz et al, 2008):
• It reduces the complexity of arranging care.
• It reduces the burden on consumers to attend multiple appointments.
• It simplifies the messages being given to consumers.
• It assists with consumer engagement by reducing the number of people consumers need to engage with.
• It reduces the time burden on services by eliminating the need to coordinate communication across agencies.
Providing integrated care within mental health treatment involves clinicians using therapeutic exchanges to address multiple issues. For example, whilst providing psychoeducation on mental health diagnosis, the clinician can speak about the effect substance misuse can have on illness progression (Arkowitz et al, 2008). Working in an integrated manner does not mean a clinician must hold more information necessarily. The clinician should be aware of avenues to go to seek out further information when the need arises.
Chronic risk
One aspect of managing complex cases involves the challenges of those consumers who present with chronic risk factors. Most commonly this is seen in cases of ongoing and chronic suicidality and self-harm.
Managing chronic risk presents several challenges for mental health clinicians:
• Chronically at-risk consumers cannot stay in mental health units forever.
• Staff often feel ‘stuck’ and unable to offer a solution.
• Staff experience anxiety that should something happen they will be held responsible.
It is important to accept that in some cases there is no solution to this issue. Instead it can be helpful to focus on safety planning and providing mechanisms for intervening when risk is at its greatest. This often involves multi-agency collaboration, as described above, to provide a system around the consumer to mitigate the risk as much is possible. However, there is a need to accept that there will always be a level of risk, despite the best efforts of the treating team.
Substance use and mental illness – a motivational interviewing approach
The most common example of co-occurring disorders in mental health is a DSM-IV-TR diagnosis and substance abuse issue. This makes up between 80 and 90 percent of all mental health presentations (Arkowitz et al, 2008). Given this large percentage, it is often the case that an integrated approach to care is most appropriate for these consumers (Rollnick et al, 2008).
The other challenge, of course, is that clients are not always motivated to change their substance use and mental health behaviours (Diclemente & Prochaska, 1998). With this understanding clinicians can rely on the principles of motivational interviewing and the cycles of change in order to assist in providing integrated interventions to these consumers (Diclemente & Prochaska, 1998). This approach is described in HSMH423 in detail and is also outlined in this resource.
READ; Meadows (2012) pp 29-30
• 10. Planning care for diverse consumersPage
10. Planning care for diverse consumers
Working with diversity
Mental illness does not confine itself to one particular type of person, and working with a diverse range of people requires a significant level of skill in empathy and understanding on the part of a clinician to ensure that services are provided in a client-centred way (Meadows et al, 2012).
Assessment is a crucial time when clinicians should seek to look beyond a simple diagnosis to also understand how the current illness has arisen in the context of the client’s life.
When considering diverse cultures it is important to understand how the client and their broader culture perceive mental health issues. For example, in some indigenous communities, when a person experiences a mental illness it is considered that the whole family is unwell and therefore must all be involved in the healing, and in some Indian cultures people with mental illness are seen to have been closer to their gods.
Understanding how the consumer conceptualises their diagnosis allows for greater understanding of how best to assist them. For example, understanding that some indigenous cultures experience a diagnosis as a community implies that in order to appropriately progress treatment the client must be treated as part of a larger system, rather than as an individual.
It is not necessary, however, for the clinician to know the intimate details of every culture they may encounter. Instead clinicians should be familiar with basic engagement and effective listening strategies to allow them to gain insight into an individual and their way of seeing the world.
The role of families and carers
Family in this context is defined as anyone committed to the care and support of the person with a mental health issue and does not have to be a blood relative.
A carer is a person whose life is affected by virtue of his or her close relationship with the consumer, or who has a chosen and contracted caring role with the consumer (usually unpaid) (NSW Minister for Health, 2007).
The Mental Health Act of NSW (2007) has identified that family and carers play a significant role in the health and wellbeing of consumers (NSW Minister for Health, 2007). There is evidence that family interventions can be as successful as other mental health interventions and have benefit across most DSM-IV-TR diagnoses (Mottaghipour & Bickerton, 2005). The Mental Health Act 2007 has made special allowances to increase the involvement of families and carers in treatment and information sharing (NSW Minister for Health, 2007).
On admission to mental health units, consumers are required to identify a primary carer who is given increased powers to be involved in all stages of care and treatment. With this increase in access comes a greater need to provide support for families and carers to assist them to be involved effectively in the care process (Furlong & Leggatt, 1996).
Typically families report that they want the following from service providers (Mottaghipour & Bickerton, 2005):
• Information & education about the illness
• Access to service providers
• To be valued as part of the treating team
• Specific suggestions for coping with the consumer’s behaviour
• Emotional support
• Access to people who face similar problems
• Timely crisis intervention
• Respite services
• Alternative living options for the consumer
• Meaningful involvement in treatment, discharge & rehabilitation planning
• Information & education about the mental health service
Integrating family work into practice
The Cumberland model of integrated family practice (Mottaghipour & Pickerton, 2005) provides a framework for all clinicians in providing assistance to families.
4. Mental health plans and the continuum of care
How are care plans developed and documented for consumers with mental illness? What are appropriate treatment protocols? How can treatment be shared effectively among health professionals in different sectors to guarantee continuity of care for consumers? Why is the skill of appropriate documentation so important?
• 1. Integration of mental health care and providing continuity of carePage
. Integration of mental health care and providing continuity of care
Providing integrated services is essential for the success of treatment. The catchcry for integrating services, before, during and after hospitalisation is ‘seamless continuity of care’. Achieving this is difficult because of the different teams of health professionals taking responsibility for care at different stages of the illness episode and each believing that their stage is the most important. However we must try to work to the principles of continuity of care identifed by Meadows et al, (2012).
The nine principles of continuity of care are:
• Supportive administrative processes
• Accessibility of the service to consumers
• Comprehensive service availability
• Individualised approach to treatment
• Flexible programs
• Linkage to other agencies
• Valued consumer/case manager relationships
• Culture of collaboration between staff and consumers
• Cultural sensitivity
When planning care there are a number of strategies that can be employed in order to provide seamless transitions from one period of care to another:
• Standardised formatting of clinical documentation.
• Integrated clinical record keeping.
• Clearly defined roles and boundaries for care.
• Effective discharge and assessment procedures.
• Effective case conferencing at the points of entry and exit from a particular phase of treatment.
• Consumer involvement in all stages of care planning (when possible).
• Comprehensive assessment and discharge documentation.
In essence, continuum of care relies predominantly on clear and effective communication and methods of working that allow all pertinent treatment data to flow between all parties involved in the care and treatment of clients. Whether treatment is carried out by one service or by multiple services it is important that treatment proceeds along the continuum in a seamless and logical manner in order to assist clients in achieving better outcomes over time.
READ: Meadows et al (2012) pp 222-225 discucusses continuum of care as a quality improvement framework
Last modified: Wednesday, 25 February 2015, 12:34 PM
• 2. Referral, scheduling and discharge pathwaysPage
2. Referral, scheduling and discharge pathways
As mentioned throughout this unit, clients may have many medical and psychosocial needs. When planning for discharge from a service it is often necessary for clinicians to make decisions about referral pathways and discharge planning. The following are considerations that should be made in consultation with the client when arranging referral and discharge:
• The number of referrals or discharge destinations. Often clients have difficulties with organising multiple referrals with different appointments in various locations. It is important that the client and/or carer understands the need for these referrals and has the means (transport and money) to get to them. If this is not the case then the health profession has to make other arrangements for the client. Travel in rural areas is particular problematic and needs to be considered before discharge.
• Prioritising of issues. The prioritising of issues should be made in collaboration with other health professionals and the client before discharge.
• Provision of information. All relevant information that is necessary for the continuing care of the client should be forwarded to ongoing service providers.
In some instances it may be possible to have a joint interview with the discharging health professional, the health professional who is about to take up the on-going care, and the client. This personal introduction and passing the care of the client onto another health professional is the most efficient way to smooth the process of continuing care because it assists the client to feel comfortable with the staff and facilities in the next stage of care.
Last modified: Wednesday, 25 February 2015, 12:35 PM
• 3. Documentation and information systems in service deliveryPage
3. Documentation and information systems in service delivery
Documentation and recording systems are essential to ensure continuity of the care and are the responsibility of the health professional. All records should be clear, readable, clinically relevant, dated and signed and made in the records provided officially by the facility. These records are important for the health of the client and persist, so every care should be taken with them.
Principles of documentation
There are a number of universal principles for good documentation.
• Always ensure you time and date all notes.
• Always sign and print your name and include your designation and role.
• Never leave blank spaces. If you need to leave a space, draw a line through it.
• Always write in black pen.
• Protect the anonymity of others. If reporting on interactions with other clients, use generic terms (e.g. an elderly client) only.
• Be objective. Do not write about what you think or feel, and do not state something unless is proven or witnessed.
• Do not use whiteout. If you make a mistake, cross it out and initial the mistake.
In order to improve client care, all health services have reporting systems for incidents that are usually defined as ‘unplanned event/s resulting in, or having the potential for, injury, damage or other loss’.
Sentinel events are incidents agreed as key indicators of system failure by all States and Territories and defined by the Australian Council for Safety and Quality as ‘events in which death or serious harm to a patient has occurred’. As part of the investigation into these events Root Cause Analysis is undertaken. This is a process used to review and analyse an incident seeking to identify, as far as possible, all causal and contributing factors leading to the incident and to identify corrective actions to minimise risk of recurrence. The spirit of the investigation should not seek to blame but should seek to find and remedy the systemic reasons for the failure to provide appropriate care. The risk is often graded in relation to the level of harm involved and a Safety Improvement Program is developed and implemented.
Unfortunately in mental health services some incidents occur that require reporting and investigation. Examples would include: wrong medication given to a patient, patient absconding from involuntary care, suicide attempt while in care, violence and assault, needle stick injury, use of illegal drugs while in care, and inappropriate behaviour by staff.
Professional attention to documentation and record keeping is very important in mental health care.
MH-OAT
The Mental Health Outcomes and Assessment Tool (MHOAT) is a standardised set of clinical records used throughout mental health services in NSW. Other states will have their own proformas but all are designed to ensure that each client is carefully assessed, treated, and discharged to on-going care experiencing the best mental health professional care possible. These documents provide guidance in relation to what should be recorded during the process of mental health care.
You should familiarize yourself with the MH-OAT guidelines provided on the Complementary CD-ROM. The MH-OAT forms are also reporting tools.
Similarly, different states will have different ‘care plans’. These are templates to record goals of care, strategies and interventions used, the person or service responsible, the expected date of completion, the date of review and the measure of evaluation.
Research
Identify in your area of work the official documentation used for care plans and the policies and programs involved.
The NSW mental health care plan template is provided for your information.You will see that in this document there is only space for recording short titles of treatment or the name of an intervention. For example:
• REFLECT & DISCUSSForum
REFLECT & DISCUSS
Reflect
Identify the policies and programs that operate in your area of current or future work with respect to analyzing sentinel events. Could these be improved? How? In framing, in implementation or both?
Post your reflections to the forum below and respond to the reflections of your peers.
• 4. Improving safety and quality in the health care sectorPage
4. Improving safety and quality in the health care sector
The Australian Commission on Safety and Quality in Health Care (http://www.safetyandquality.gov.au/) was established by the Australian, State and Territory Governments to develop a national strategic framework and associated work program to guide its efforts in improving safety and quality across the health care system in Australia. (See: http://www.safetyandquality.gov.au/our-work/national-standards-and-accreditation/)
The Commission commenced on 1 January 2006.
The Commission’s role is to:
• lead and coordinate improvements in safety and quality in health care in Australia by identifying issues and policy directions, and recommending priorities for action
• disseminate knowledge and advocate for safety and quality
• report publicly on the state of safety and quality including performance against national standards
• recommend national data sets for safety and quality, working within current multilateral governmental arrangements for data development, standards, collection and reporting
• provide strategic advice to Health Ministers on best practice thinking to drive quality improvement, including implementation strategies, and
• recommend nationally agreed standards for safety and quality improvement.
The work of the Commission involves:
Accreditation: The primary objective of the project is to provide Health Ministers with an alternative model of accreditation that can be applied across all sectors of the health care system.
Australian Charter of Healthcare Rights: The Commission has worked with the Consumers Health Forum and other organisations to develop an Australian Charter of Healthcare Rights that provides information about the rights of patients and consumers to underpin the provision of safe and high quality care, and to support a shared understanding of the rights of people receiving care.
Clinical Handover: The purpose of this program is to identify, develop and improve clinical handover communication. Safe health care delivery for patients depends on effective communication between health care providers. Developing and implementing more consistent and reliable approaches to clinical handover is a key strategy to reduce communication errors.
Credentialling for health professionals
Falls Prevention: Guidelines preventing falls and harm from falls in older people: Best practice guidelines for Australian hospitals and residential aged care facilities
Healthcare Associated Infection (HAI): The aim of the Commission’s HAI program is to formulate a national approach to HAI including strategies for ensuring practices are sustained and the development of an agreed National Plan for healthcare-associated infection prevention. The project will focus on identifying and addressing systemic problems and gaps and ensuring a comprehensive range of action is undertaken in a nationally coordinated way by leaders, decision makers and public and private providers operating at different levels in the health system.
Information Strategy: The program will provide national leadership and coordination in national improvements to the evidence base for safety and quality, via the development, analysis, use and reporting of information that monitors and equips actions to enhance the safety and quality of health care. The program of work is set out in the Information Strategy. There are four streams of work, designed to achieve key aims for the Commission specified by Ministers and to support information developments required by other priority programs.
Medication Safety: The objective of this program is to improve the safety of medication usage in Australia. Effective and safe use of medication is one area where potential improvements in the safety and quality of health care can be made. Because of the multiplicity of current and proposed initiatives in this area, there may be a key coordinating role for the Commission.
Open Disclosure: Open disclosure is the open discussion of incidents that result in harm to a patient while they are receiving health care. The National Open Disclosure Standard (the standard) outlines the essential elements of open disclosure. The purpose of this project is to support jurisdictions and facilities to implement the standard. This will involve translating the findings of the national pilot of the standard into useful tools for clinicians and patients, and undertaking work to overcome the legal barriers to open disclosure and to explore patients’ experiences of open disclosure.
Patient Identification: This program is a national response to the continuing problem of patient misidentification. It is focused on key areas of activity where the Commission can deliver leadership for national action, coordinate agreed standards for performance, and support jurisdictions and private health providers in their implementation of protocols and agreed safety improvement actions.
Recognising and Responding to Clinical Deterioration: This program is to explore what national work can improve the safety and quality of care for the patients at risk of unexpected cardiac arrest or serious morbidity, including consideration of communication of critical test results.
Several of the publications available at the Commission web site provide important reading for health professionals.
We will end this module by asking you to read this article on Current issues in mental health service provision in Australia. Professor Cobie Rudd stresses the importance of safety and quality in mental health services, while Associate Professor Nicholas Procter emphasizes the importance of communication between health professionals, the client and carer in improving mental health services in Australia.
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