Mental Health Emergency Care - Rural Access Program

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Improving Access to Acute Mental Health Care
despite great distance and limited resources
Prepared by Dr Martyn Patfield Mental Health
Emergency Care Rural Access Programme Greater
Western Area Health Service
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Aim

• To provide readily accessible, reliable and
  useful Mental Health assessment and management
  input to health staff in rural hospitals dealing
  with mental health emergencies, where
  conventional resources are not availablevia
  video technology
• And therefore
• Safer and better quality care
• Less inappropriate transportation to inpatient
  units
• Improved mental health skills in general ED
  staff

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Nature and extent of the problem

• Since 1990, the rate of inpatient psychiatric
  admission has more than tripled.
• Most of the population of GWAHS lives in
  communities not serviced by an inpatient
  psychiatric facility.
• The resulting increase in demand for
  transportation, especially with police and
  ambulance escort, has tested resources (and
  tempers). Towns are left without emergency
  services.
• Limited MH staffing means that expertise often
  cannot be available where and when it is needed.

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Admissions to Orange Psychiatry

inpatient unit, 1990 - 2006
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Strategic importance

• National Mental Health Policy 2008
• 2.5 Access to the right care at the right
  time
• People with mental health problems and
  mental illness will have timely access to high
  quality, coordinated care appropriate to their
  condition and circumstances, provided by the most
  appropriate services.
• So something had to be done.

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Planning implementing solutions

• 2005 NSW Health charges rural MH services with
  development of models to deal with acute MH
  presentations
• 2006 widespread consultation (inc ED staff,
  GPs, Police, Ambulance, Aboriginal health,
  Hospital transport, etc) throughout GWAHS about
  an early iteration of MHEC-RAP
• 2007 Planning and recruitment of staff (from
  within Bloomfield Hospital) and redevelopment of
  an old ward in Bloomfield. Training and placement
  of equipment
• 2008 Clinical operations begin in February 2008

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The GWAHS solution MHEC-RAP, a virtual
consultation-liaison team

• Central team 24/7 nurses (2 per shift)
• psychiatrist in
  office hours (and on-call A/H)
• Free call 1800 number for mental health
  information and support. (Already in
  place)
• Structured Triage
• Video assessment Nurse and/or Psychiatrist
• Management advice till problem resolved
• Liaison Police, Ambos, EDs (peripheral and
  central), MHIPUs, on-call psychiatrists,
  families, GPs, Community MH, etc
• Training for local general hospital staff.

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Important Elements - why it works.

• Active engagement of local general nursing staff.
• Trust and relationship between the central team
  and local staff............. Thus, reduced sense
  of isolation and greater confidence to deal with
  Mental Health presentations.
• Strong psychiatrist presence to support nurses in
  central team.
• Accessible equipment which is easy to use.
• A goal is to increase the psychiatric skills of
  the local general hospital staff.

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Outcomes evaluation

• Formal evaluation through 2008 by the Centre for
  Remote Health Research, University of Sydney.
• Steady increase in utilisation.
• Rising levels of confidence in EDs.
• Reduced inappropriate transportation (but also we
  recommend admission for those who might otherwise
  have been missed). Less admissions. Admissions
  more often locally rather than to distant
  psychiatry units.

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Transport to Inpatient Unit vs Tendency to use
MHEC RAP
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Sustaining change

• Regular training visits to feeder towns (which
  includes delivery of mandatory training to
  nursing staff)
• MHEC RAP involvement in all MOU Meetings between
  Health, Police and Ambulance. (External pressures
  to encourage use of MHEC involvement with
  emergencies)
• Clinical governance processes, especially daily
  review of triages and video assessments

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GWAHS Map MHEC-RAP Training Sites

• 08-09 Sites where training was conducted
• Future sites

Coonabarabran
Wilcannia
Warren
Balranald
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Lessons learned

• Technology simple is better. (Beware the geeks)
• Accept evolution (Many changes to our original
  model including safe assessment rooms and
  1800 number as a separate entity)
• Measurement is useful (e.g. Aggression is not
  as frequent a problem as is usually thought)
• Measurement has limited use (Trust and
  professionalism are keybut can they be
  measured?)
• People Its the staff that makes it work, not
  the machines

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Photo of team
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Future scope

• Community Mental Health Services are stretched
  MHEC may provide a basis for support and
  development.
• GPs have limited access to psychiatry support
  MHEC may extend into less acute MH problems.
• MHEC-RAP role in support of potential declared
  mental health facilities under the 2007 MHA.

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Presentations at AE Behavioural Types
First 18 months. Triages
Aggression 231
7 Threats Suicide/ DSH 1373
42 Confused/Psychotic 672
20 Anxiety/depression 689
21 Intoxication/ DA 48
1.5 Other 206
6 TOTAL
3219
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Patient Interview Numerical Responses(First
year evaluation report, University of Sydney)

Was the service prompt and timely to your needs? Not timely 1 Somewhat timely 2 Timely 3 Better than timely 4 Very timely 5 4.08
What do you think of the video system, was it easy to use and helpful? Not helpful 1 Somewhat helpful 2 Helpful 3 Better than helpful 4 Very helpful 5 4.18
Was the care well organised between your location and the other? Not organised 1 Somewhat organised 2 Organised 3 Better than organised 4 Very organised 5 4.39
Number of respondents that would use the service again or recommend it to someone for use 25/31