Going Against the Trend - But With Good Reason

• Abstract
• Introduction
• The Past
• The Traditional System
• Analysis
• Fixing the System
• Integrated Treatment Planning
• Integrating Care in Crisis with Care in the Community
• The Evidence

Abstract

Changing the way in which clinical care is delivered requires thorough analysis and clear decision-making. It also requires courage if the change is not supported by current popular trends. This paper describes changes to clinical care delivery implemented at MidCentral Health’s Mental Health Services. Preliminary results are encouraging.

Introduction

MidCentral Health’s Mental Health Services holds the contract to provide comprehensive mental health care to a population of approximately 160,000. The Service employs mental health professionals from all disciplines and provides all aspects of mental health care including inpatient care, community care, crisis care, general hospital liaison, child, adolescent and family service, alcohol and drug services and Maori mental health services. This paper describes recent changes made to the way mental health care is delivered by the MidCentral Mental Health Service and the rationale for those changes.

Although changes are at an early stage, this paper serves to inform the sector about the model of mental health care adopted by the MidCentral Health’s Mental Health Services and aims to stimulate further discussion and innovation in delivery of mental health care.

The Past

A series of adverse incidents leading to high profile inquiries, a continuously increasing financial deficit, an over supply of acute inpatient care and inability to gain consensus about how a service should be managed are valid reasons for any mental health care provider to consider whether things should be done differently. This was the reality for MidCentral Health’s Mental Health Services. The situation was quickly becoming unmanageable with an inherent risk for both the consumers and the organisation.

Mention structuring mental health care services differently and the usual reaction is "the whole country provides mental health care this way. It must be government policies, the weather, a power game of some sort, unreasonable expectations of politicians and consumers, inadequate remuneration of staff, too many managers - that must be the reason for this mess". Not an easy argument to address, "Well, maybe . . ."

Doing things differently means change and in the current health environment it is not fashionable to talk about change. Health care professionals often look back and complain, "we have been through too much change; it hasn’t made a difference until now; there is cost attached to change and we haven’t got money; change is disruptive, etc".

However, how else would people be able to get out of the vicious circle of adverse incidents, constant scrutiny, disenchantment, omissions and more adverse events. The reality is that in our practice health professionals embrace change every day without realising it. This phenomenon is no different from the changes in a growing child that parents do not notice everyday but on looking back, find the child has indeed grown.

Doing things differently also requires courage because coming out "worse off" is always a risk. It is also a challenge, especially if there are no extra resources available and the mental health care service has been told "There ain’t any for you Mate! You are already in the red."

When faced with these issues, the one thing the MidCentral Health Mental Health Service (MCH MHS) did not lack was courage. There was an appreciation about what needed to be done. It was just a matter of finding an excuse for doing it.

The Traditional System

As mentioned above MCH MHS was contracted to provide comprehensive mental health care to a population of about 160,000. Mental health care was provided through community facilities, the Inpatient Unit and the Day Hospital and Day/Rehabilitation Centre.

Structurally, MCH MHS was divided into the Crisis Assessment and Treatment Team (CATT), the Inpatient Team, the Subacute Team, the Day Hospital Team, several Community Teams (for each geographical region), Oranga Hinengaro (Maori Mental Health Team), the Child and Family Team and the Alcohol and Drug Service.

All teams functioned as stand-alone teams. A formal process of referral operated between teams and consumers were moved from one team to another depending upon the kind of intervention required.

This process had several advantages including:

1. Mental health service disciplines were represented in each team and members of each team were able to make comprehensive assessments of consumers’ needs and provide the level and type of intervention required.
2. With all sub-units of the MCH MHS being "stand-alone" teams, each sub-unit was able to specialise in its area of expertise (eg, CATT: Crisis assessment and acute intervention; Inpatient Units: hospital acute and intensive care; Community Teams: care and follow-up in the community).
3. Acute services (CATT and Inpatient Units) being separate from the community teams allowed the community teams to function in a planned and co-ordinated way. Therefore, consumer appointments could be booked in advance and community team staff went about providing care in the community without any distractions from crises when they occurred.

However, such a configuration also had many disadvantages:

1. It interfered with the provision of continuity of care. Inevitably, referrals from one team to another meant changes in therapists and other personnel providing consumer clinical care. Moreover, all teams appeared to have different treatment philosophies. Inevitably, with the move of consumers from one team to another there was a change in treatment plans which sometimes left the consumers unsure about the treatment being provided.
2. The process of formal referral from one team to another often meant delays between receipt of referrals, assessment of consumers and provision of care by accepting teams.
3. Consumers referred from one Team to another (eg, from CATT to the Inpatient Unit and then to the Community Team), had to undergo a series of assessments. Often there was an unnecessary duplication of assessments, many times by several specialists, and definite treatment plans could not be put in place until the consumers reached the Community Team.
4. With the mental health specialists very thinly distributed over many teams, some teams did not get the benefit of their expertise at all, and others got only minimal input.

Analysis

On close analysis of the existing MCH MHS system it was clear that the disadvantages far outweighed the advantages and that things had to be done differently.

We did not require "Bob the Builder" to identify what needed fixing. Obviously, several formal inquiries undertaken by MidCentral Health, and learning from adverse incidents that had occurred, were immensely helpful. It was clear that MCH MHS’s problems lay in a fragmented system of care and that it did not have the infrastructure to provide appropriate co-ordination of mental health care services.

Because of the way the mental health service was structured, clinicians were locked into their own facilities unable to maintain continuity of care for consumers. In fact, the system of care also provided opportunities for perverse incentives for clinicians to "hand over" rather than "look after" consumers when the going got tough.

Cynics were quick to identify the irresistible desire that community clinicians had to overcome - to keep "looking after" a consumer rather than admitting that consumer to an inpatient unit. Not to mention a similar impulse of clinicians in the inpatient unit to discharge someone into the community (in some one else’s care), if that were possible.

In this system as consumers moved from one facility to another, he or she became the responsibility of another set of clinicians with each move. Because of the way the service was structured, clinicians locked in their own facility, were not able to fully appreciate what was happening in other facilities. In many instances, they did not have an opportunity to determine whether clinicians to whom they were referring consumers had the ability, expertise or resources to meet the consumers’ needs adequately.

A bureaucrat would argue memorandums of understanding, better co-ordination, explicit policies and education and training would be simple ways of resolving such a problem. Indeed, that had been an argument all along. However, MCH MHS accepted the possibility of that tiny red devil who kept poking his pitchfork into the heart of well-meaning clinicians from time-to-time saying, "… pass the consumer to some one else, pass the consumer to some one else...". MCH MHS wondered whether it was necessary to make the system more co-ordinated and less fragmented rather than patching up a fragmented system with memoranda that would then have to be debated and argued to their demise. Whether there was a way to ensure that any perverse incentives were deleted from the equation!

Fixing the System

The first step was to put a stake in the ground, which meant a non-negotiable stance that continuity of care for consumers must determine how the services would be delivered. This, along with a drive to become efficient and effective, also meant it was imperative to ensure that there would be minimal duplication of efforts, both in activities and processes.

"Improving continuity of care for the consumer" and "minimal duplication" became the vision for MCH MHS. Every existing process and each new initiative was tested against this gold standard. Only those initiatives that satisfied this standard were retained.

Integrated Treatment Planning

To achieve the twin goals of improving continuity of care and minimising duplication it was essential to find a way to ensure that there was one treatment plan for each consumer and that different teams were not developing their own individual treatment plans. At the same time it was also considered to be important to ensure that, as far as possible, these single treatment plans were developed with the participation of the consumers, their families and care givers, where appropriate.

An integrated treatment planning policy and process was developed so that consumers’ integrated treatment plans followed the consumers irrespective of which facility was treating them. At the same time, processes were put in place to ensure that clinicians were no longer locked in their facilities and that they could work across facilities.

Integral to the integrated treatment planning process is a philosophy that as long as consumers have an affiliation with the mental health service, their key worker and psychiatrist continue to coordinate his/her care and treatment irrespective of whether the consumers are receiving care in the community, as an inpatient, or presenting with a mental health crisis. This also meant that the little red devil could not keep tempting well-meaning clinicians to pass on responsibility of care to someone else in the system, unless there was a clinically relevant reason to do so.

Integrating Care in Crisis with Care in the Community

MCH MHS also considered that if its intention was to ensure continuity of care for consumers, it did not make sense to allow the most stressful time in consumers’ lives, those few hours when they may be experiencing a mental health crisis, to be fragmented away from the care they were receiving from the MCH MHS. Common sense dictates that, to whatever extent possible, it is important that consumers experiencing a mental health crisis are able to receive care from people they know rather than from someone who knows nothing about them.

Some reactions to the suggestion that crisis care should be subject to the same continuity of care principles were:

"Are you saying we should dissolve the crisis team?"

"How preposterous. Most mental health services in New Zealand are creating Crisis Teams".

"The Mental Health Commission in New Zealand is undertaking a review of Crisis Teams presumably to strengthen the structure and processes of the Crisis Teams."

"It is going to be difficult for the community clinicians to disrupt their planned appointments to deal with psychiatric emergencies. This will cause unnecessary turbulence to their well-structured daily routines".

"Attending to psychiatric emergencies will mean cancellation of appointments at short notice and needless to say, interfere with therapeutic relationships . . ."

Does make sense though, doesn’t it?

"The consumer will be saved from the agony of approaching an unknown person to seek help at a time when he/she is most vulnerable. It may take the consumer’s own clinician 5 minutes to understand what is happening in the life of the consumer and why, whereas it may take an hour or more for another clinician who does not know the consumer to understand what is going on. Clinicians may be able to schedule appointments to prevent the need of unplanned contacts, therefore, decrease the likelihood of occurrence of a mental health crisis. It is also likely that the consumers will have more confidence in the system if they knew who they could contact if they have a query rather than speak to a voice they do not know."

Yes, we do integrate care in the crisis with care in the community but still have a back-up system to deal with unplanned and unanticipated contacts. However, to whatever extent possible the consumer should be able to see his/her own clinician.

Remember that stake in the ground to ensure continuity of care for the consumer. . .

The Evidence

The proof of the pudding is in the eating. Unfortunately, it is still too early to tell whether the changes introduced over the last 18 months have made a difference. There are several confounding real-life variables that just do not allow definite conclusions to be reached at this time. It is hard to say whether difficulties in recruiting psychiatrists (that resulted at one time in the reduction of medical staffing to less than 50% of contracted staffing levels and of non-medical staff), depletion of the ozone layer, a harsh winter, change in government, or the fact that the majority of staff in the MHS are keeping their fingers crossed, have influenced outcomes.

One thing is certain though, something has changed.

• The MCH Board and the CEO have experienced a reduction in stress levels caused by worrying about the MHS and less time is now spent by the Board on MHS-related matters.
• The CEO has indicated increased confidence in the MHS.
• A MHS that was in the red (financially) for the last five years has suddenly broken even and is now making a contribution towards the whole MCH organisation’s overheads.
• The number of complaints and the time taken to resolve complaints have fallen considerably
• Complaints about staff attitude (as perceived by consumers) and inadequate care have decreased
• Average inpatient occupancy that used to be over 100% almost all the time has not been more than 95% since the changes were implemented, and at times significantly lower.
• There has not been even a single major incident or a high profile inquiry since the changes were implemented.
• Risk is managed appropriately.
• Despite staffing shortages from time to time there is no sense of crisis within the service.

Something must have changed!

The purpose of this case study has been to inform the mental health sector and to disseminate information about the model of care that the MCH MHS has adopted. This was not an action research project and therefore no objective measurements were made to measure success or failure of this model. However, objective data on performance indicators are being analysed.