Addiction and Mental Health Services Psychosis · PDF fileMetro South Addiction and Mental...

Metro SouthAddiction and Mental Health Services

November 2014

Model of CareModels of care set the standard for care

PsychosisAcademic Clinical Unit

Great state. Great opportunity.

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Our visionProvide our community excellence in consumer and family centred, integrated services across the continuum of addiction and mental health care.

Our missionDemonstrate exceptional care to consumers experiencing addiction and/or mental health problems to reduce the burden of disease and to integrate care with our key health partners.

Our core valuesMetro South Health Addiction and Mental Health Services has six core values that define and determine how we embrace our day-to-day work.

Addiction and Mental Health Services

Service provision is based on principles outlined in (but not exclusive too) the following reference documents:• Roadmap for Mental Health Reform

2012‑2022.• FourthNationalMentalHealthPlan.• National Practice Standards for the Mental

Health Workforce 2013.• National Standards for Mental Health

Services 2010.

• Clinical Services Capability Framework(v3.1)

• National Mental Health RecoveryFramework2013.

• Queensland Health Strategic Plan 2012-2016.

• QueenslandPlanforMentalHealth2007to2017.

• HealthServicesAct,1991.• MentalHealthAct2000.

1. Courage

To challenge what is the status quo and lead change.

2. Leadership

To guide with purpose and direction through acceptance of responsibility and accountability for the services we provide.

3. Team work

We work in a supportive, transparent, responsible and answerable manner.

4. Respect

We treat consumers, families, carers and staff with equality and consideration.

5. Integrity

We demonstrate honesty, loyalty and sincerity.

6. Caring for people

To help, assist and guide individuals to achieve their goals.

Our service culture is based on the focused delivery of care to consumers, their families and carers, within a framework that encourages hope and the building of resilience.

Acknowledgments

PreparedbytheModelofCareProjectTeam

Project Sponsor Professor David Crompton

Project Manager Peter Kohleis

Contributors Dr Balaji Motamarri

Anne Steginga

Mandy O’Driscoll

Quality and Governance Team

Addiction Services Team

Social Inclusion and Recovery Team

Editor Amanda Carins (Communications)

Abbreviations

MSAMHS Metro South Addiction and Mental Health Services

ACT Acute Care Team

ACU Academic Clinical Unit

ABF Activity Based Funding

ATAPS Access to Allied Psychological Services

CIMHA Consumer Integrated Mental Health Application

CALD Culturally and Linguistically Diverse

CM Case Manager

ED Emergency Department

HONOS Health of the Nation Outome Scale

MDT Multidisciplinary Team

MSH Metro South Health

MoC Model of Care

PSP Principle Service Provider

QHEPS Queensland Health Policy Intranet Site

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Model of Care Psychosis Academic Clinical Unit4

██ ContentsForeword 5Part 1: Psychosis Academic Clinical Unit 61.0 Introduction 61.1 Service requirements 81.2 Consumers 101.3 Service locations 101.4 Guiding philosophy 101.5 Service funding 111.6 Clinical framework 122.0 Introduction 14Part 2: Care in the community 142.1 Service program activities 162.1.1 Referral 162.1.2 Intake 172.1.3 Assessment 192.1.4 Treatment 212.1.5 Recovery planning 242.1.6 Continuity of Care 252.1.7 External Transfer of Care 262.1.8 Internal Transfer of Care 272.1.9 Partnerships 272.1.10 Working with carers and families 282.1.11 Team approach 292.1.12 Clinical review 302.1.13 CIMHA 31Part 3: System-of-care 323.0 Introduction 323.1 Hours 323.2 Workforce 323.3 Roles and responsibility 333.4 Leadership 353.5 Governance 363.6 Case load 383.7 Consumer engagement 383.8 Sector engagement 393.9 Supervision 403.10 Training 423.11 Documentation 43Part 4: Appendix 464.0 Assessment measures 46

Model of Care Psychosis Academic Clinical Unit 5

Metro South Addiction and Mental Health Services (MSAMHS) is responsible for implementing clinician-designed Models of Care and other clinical innovations. These Models of Care reflect the needs of mental health consumers and are based on ‘best’ evidence approaches to health and wellbeing service provision.

The implementation of formalised Models of Care is relatively new within MSAMHS, particularly when linking the Model of Care to ‘clinician activities’.

The aim when implementing the Models of Care is to achieve a balance between improving consumer outcomes and ensuring efficient and effective use of specialist mental health resources.

The Model of Care has been prepared by and for the Psychosis Academic Clinical Unit’s clinicians to:

5 articulate and implement the objectives, principles and values of MSAMHS

5 provide high level explanation of key service provision elements 5 describe how service provision is linked to economic indicators 5 describe how services are integrated across the specialist mental

health and mainstream healthcare system.

“ “Researchhasledtoanincreasingnumberofeffectivedrugstochoosefromandarangeofevidence-basedpsychologicaltreatments.Weknowmoreabout‘what

works’.Wenowneedtomakesureeveryoneisofferedthetreatmentsthatweknowworkbest,deliveredwithkindness

andcompetence.

Professor Sir Robin Murray. Hearing Voices World Congress in Cardiff Wales 2012.

██ Foreword


Part 1: Psychosis academic clinical Unit

██ 1.0 IntroductionMetro South Addiction and Mental Health Services (MSAMHS) is a specialist area of healthcare that promotes optimal quality-of-life for consumers with mental ill-health. The specialist services are concerned with the assessment, diagnosis, monitoring and treatment of consumers who have a mental health disorder characterised by a clinically significant disturbance of thought, mood, perception, memory and/or behaviour.

Specialties within MSAMHS address the needs of a broad mix of consumer types across the entire age spectrum (children, adolescents, adults and older persons). A consumer’s need for specialist service provision can be short, medium, long-term or intermittent, and often spans various levels of care and service areas.

MSAMHS’ services are delivered by the specialist Academic Clinical Units (ACU). The Psychosis ACU is one of the key specialist providers in the integrated addiction and mental health services. Each ACU is charged with meeting service and funding efficiencies relevant to their specialty. Beside the Psychosis ACU other specialist ACUs include:

5 Resource and Access Services (RAS) 5 Mood 5 Older Adult 5 Child and Youth (C&Y) 5 Consultation Liaison (CL) 5 Rehabilitation 5 Addiction Services 5 Transcultural Mental Health.

Metro SouthAddictions &

Mental Health Services

PsychosisModel of Care


Individuals access the services of MSAMHS through the RAS ACU and are then transitioned to the Psychosis ACU and other specialist ACUs based upon their needs, age and their primary diagnosis (Diagram 1).

Academic Clinical Units

Access / Entry

Quality & Governance, Information Management, HR, IR

Research, Service Development, Education, Training

Funding, Business Services, Asset Management, Safety

Community Service Delivery Partnerships NGOs, GPs, ATAPS, private sector providers, government agencies, community groups, peer support workers, vocational support officers

Child and Youth Mental Health

Older Adults

Psychosis

Mood

Addiction

Consultation Liaison

Transcultural Services

Rehabilitation

Logan Wellbeing Program

(an additive model taking

referrals from the ACUs)

Enabling Services

Specialist Mental Health Services

Sing

le P

oint

of E

ntry

Resource & Access Services

1300 MH-Call

Acute Care Team

Hospital ED

Diagram 1: MSAMHS ACUs (service groups)


The Psychosis ACU routinely attends to the special needs associated with the mental health of:

5 Aboriginal and Torres Strait Islander peoples 5 people of culturally and linguistically diverse (CALD) backgrounds 5 people living in rural and remote areas 5 people with a comorbidity or complex needs - this may include, but is not

restricted to, consumers with a mental health diagnosis as well as:• an intellectual disability• a substance-use disorder• a dementing illness or other brain disorder/s• severe or complex medical problems• a sensory impairment• a forensic history.

██ 1.1 Service requirementsUnder the National Mental Health Strategy, the Clinical Services CapabilityFramework (CSCF V3.1) provides a broad guideline on service delivery and workforce requirement, defining the Psychosis ACU service group as a Level 5 Ambulatory (community) Mental Health Service. As such, service delivery requirements include:

5 multidisciplinary assessment and specialised interventions by mental health professionals; a designated care coordinator/case manager; documented frequent case reviews that include outcome measurement; consumer and carer support and education; all levels of relapse prevention programs/services; evidence-based treatment interventions that include vocational assessment and support, socialisation, nutrition, exercise; consultation-liaison with other healthcare and related services; peer support worker engagement; extended-hours service; and, service delivery transfer to mainstream and other healthcare services

5 service delivery to the highest risk/complexity voluntary and involuntary mental health consumers

5 the development and use of care pathways that inform the assessment, diagnosis, monitoring, treatment, evaluation, ongoing care, referral and transfer of consumers

5 any interventions required in the management and containment of violent and/or self-harm behaviours


5 episodes of care being ‘comprehensively’ documented in the Consumer Integrated Mental Health Application (CIMHA)

5 engaging consumers, their family and carers 5 promoting and ensuring Continuity of Care.

Under the CSCF the workforce requirements support:

5 services being delivered by a multidisciplinary team that includes the following professionals and supports:• psychiatrists and other medical doctors• nursing • social work • psychology • occupational therapy• peer support workers• transcultural advisors• administration staff.

5 clinicians employed to the Psychosis ACU demonstrate high levels of clinical expertise in the assessment, treatment intervention and evaluation of consumer care

5 clinicians are engaged in ongoing education and training in clinical and safety programs relevant to the clinical practices of the Psychosis ACU

5 clinicians participate in clinical practice supervision with clinician/s who are trained / experienced in service delivery to people with psychosis and schiziphrenia

5 clinicians hold professional qualifications and if required, are currently registered with the Australian Health Practitioner Regulation Agency (APHRA)

5 clinicians access on-demand interpreter services (e.g. language and sign language) if required

5 clinicians access support services and if possible service providers as required with expertise in:• Aboriginal and Torres Strait Islander mental health• transcultural mental health• dual diagnosis (e.g. mental health disorder plus alcohol/other drug

disorder)• consumer and carer support needs (Peer Support Workers).


██ 1.2 ConsumersThe Psychosis ACU routinely provides services to:

5 consumers (aged 18 years to 65 years) with an ICD-10 diagnosis of Schizophrenia and related disorders (ICD-10 F20 classifications)

5 consumers who live in the Metro South Hospital and Health Service (MSHHS) catchment areas

5 consumers under the QueenslandMentalHealthAct2000 (and who meet the criteria for entry to the Psychosis ACU)

Those consumers whose primary needs are associated with alcohol and drug problems, intellectual disability, requests for a medicolegal report alone and social or domestic problems are transitioned to primary care, private practice specialists and other service programs.

██ 1.3 Service locationsThe Psychosis ACU teams are based in:

5 Logan-Beaudesert Hospital catchment area• Browns Plains Clinic• Logan Central Clinic• Beenleigh Clinic

5 Redlands Hospital catchment area.• Bayside Clinic (including the Bay Islands)

5 Princess Alexandra Hospital catchment area• Inala Clinic• Macgregor Clinic• Burke Street Clinic.

██ 1.4 Guiding philosophyThe Psychosis ACU service group is informed by the values inherent in the recovery model, services are:

5 consumer-oriented (rather than illness-oriented) 5 involve the consumer in the planning and implementation of services


5 show respect for self-determination and choice 5 focus on social inclusion, health and resilence.

Service delivery is integrated and incorporated across inpatient and community settings. Irrespective of the location, the recovery model guides the clinicians interactions. Emphasis is on Continuity of Care, paying particular attention to the closure of service gaps and the removal of barriers that might impede the consumer’s access to further services and recovery.

██ 1.5 Service funding It is important clinicians recognise funding for the Psychosis ACU, like all other ACUs, is reliant upon clinicians accurately recording their service activity (recording episodes of care, admissions, appointments, case reviews, assessments and treatment interventions - including outcome measures (serial HONOS) for each and every consumer).

A consumer of the Psychosis ACU will attract funding based upon either an assessment or treatment service provided (Diagram 2):

To obtain the funds needed to maintain service delivery, clinicians must record the following minimum requirements:

1. Assessment funding requires a provision of service that includes an assessment or intake intervention. This may include triage / initial assessment, mental status assessment, comprehensive mental health assessment, or intake triage.

2. Treatment funding requires:

5 a current diagnosis. Diagnoses must be reviewed and confirmed by a psychiatrist and/or multidisciplinary team every 91 days (note: diagnoses entered in the CIMHA outcomes module are not considered)

Psychosis ACU

Assessment

Treatment

Does the consumer require ongoing care?

No

Yes

Assessment funding

Treatment funding

Diagram 2: Funding elements


5 a provision of service in which the consumer participates in person or by video conference

5 a provision of service that includes a multidisciplinary case review or other review. This is not required for packages that are less than 91 days in length

5 a valid outcomes collection using the HONOS from the National Outcomes Casemix Collection (NOCC).

██ 1.6 Clinical frameworkClinical teams and individuals within the Psychosis ACU focus their efforts on three service delivery domains (Diagram 3).

The clinical framework emphasises the benefits of combining physical healthcare treatments with behavioural and lifestyle interventions. The framework exhibits a biopsychosocial approach to mental wellbeing. Clinicians are expected to incorporate each of the three domains into the individual consumers recovery plan.


Domain 2 - functioning:• community adjustment • coping skills• reactions to illness • social supports, activities,

needs• family supports, relationships,

needs• peers, friendships• culture/religion• housing, finances, ADLs,

healthy lifestyle interventions• occupational/vocational

(work, school, supported employment).

Domain 3 - comorbidities:• disability• substance use and abuse• side effects • mood (depression, anxiety,

distress)• physical wellbeing (diabetes,

infectious disease).

Domain 1 - symptoms:1. Positive:• hallucinations• delusions• speech and behavioural excess2. Negative:• affective blunting• amotivation• anhedonia• avolition• alogia3. Disorganisation:• disorganised behaviour4. Cognitive:• memory• information processing• attention / concentration• competency• executive functioning5. Risk:• to self• to others.

Diagram 3: Clinical framework

Three service delivery domains:

Consumers


Diagram 4: Consumer-focused activities

Better outcomes for consumers, families,

carers and community

A partnership approach - linking and engaging

with our community

Accountability and confidence in the

health system

Excellence in clinical care, education and

research

Strategic priorities Consumer-focused

activities

1. Referral

10. Family/carers

12. Case review

3. Assessment4. Treatment

5. Recovery and planning

6. Continuity of care

7. External transfer of care 8. Internal transfer of care

2. Intake

11.Team approach 13. CIMHA

9. Partnerships

Part 2: care in the commUnity

██ 2.0 IntroductionUnderpinning the Psychosis ACU community service program is the AddictionandMentalHealthServicesStrategicPlan(2014-2017). The four strategic priority areas guide the day-to-day consumer focused activities of the Psychosis ACU (Diagram 4).





The Psychosis ACU service program asserts that symptoms and functioning are improved when the consumer systematically obtains the right services, at the right time, in the right place by the right providers. Part 2 of the Model of Care, Care in the Community, looks at the key community services offered to consumers, carers and families.

The key principles that guide the Psychosis ACU service provision ensures all new cases having:

1. An assessment for severity of illness (Domain 1 - symptoms) and a needs assessment is completed at intake.

2. The intake assessment incorporates the NOCC measures as well as the Psychosis ACU specified outcome measures (Appendix 1).

3. The comprehensive assessment evaluates the consumer’s functional capabilities and needs (Domain 2 - functions).

4. The intake and full assessment investigate comorbidities (Domain 3 - comorbidities).

5. A written plan is developed (with the consumer, whenever possible).

6. Plans are shared with the consumer (and carers and families, with the consumer’s permission).

7. Specialised therapies are initiated within 2-3 weeks of the consumers first contact.

8. Consumers and their families or carers are also provided with the following additional information:

5 how to access the 24 hour 7 day crisis care 5 how to access acute care (including inpatient care) 5 how to obtain nonmedical crisis support 5 how to obtain at home support 5 how to access community-based rehabilitation and support 5 how to obtain addiction service support 5 how to access non-mental health treatments (diet, exercise,

socialisation) 5 how to access employment and education opportunities 5 how to access supported / affordable housing.


██ 2.1 Service program activities

██ 2.1.1 Referral

Description Access to the specialist assessment and treatment Psychosis ACU is especially important, particularly as the quality-of-life for consumers is greatly enhanced when the specialised treatments are initiated sooner, rather than later.

Referral to the Psychosis ACU often follows other healthcare interventions (e.g. RAS services, ED presentations, inpatient services, primary care services, community service care and other services). Collateral information is gathered to reduce service duplication and wasted time and effort, whenever possible.

The referral pathway into the Psychosis ACU is illustrated in Diagram 1. Referrals on the standard MSAMHS referral form are forwarded to the local Psychosis ACU email account.

Referrals will originate from the following sources:

5 1300 MH CALL (triage) 5 Acute Care Teams (mobile outreach teams) 5 Hospital ED, and / or 5 Inpatient Services.

Referrals however, may also include self and assisted referrals, for example:

5 a doctor-to-doctor transfer is initiated (e.g. Hospital Health Service to Hospital Health Service, ACU to ACU).

5 a past consumer may re-contact the local Psychosis Team 5 a GP may seek advice and assistance fearing a relapse for a previous

consumer of the service.

Procedure 5 The local Psychosis ACU clinic Administration Officer routinely monitors

and manages the email account, printing and handing off the referral to the team leader.


5 The team leader screens the referral for appropriateness and priorities. 5 The referral is allocated to a case manager. 5 The time taken from the referral being received to the consumer being

seen is routinely monitored by the team leader. 5 Time-frames, from referral to Intake assessment, will be formulated

according to the consumers clinical needs (consumers at greater risk are urgently assessed). In the event the initial assessment is not undertaken within the stated timeframe, a clinical review by a senior clinician with an updated risk assessment is documented on CIMHA.

5 If a new consumer self refers direct to the Psychosis ACU (by-passing the usual referral pathway), the referral information is provided to 1300 MH CALL (RAS ACU) which will complete a triage assessment and action the appropriate service placement.

██ 2.1.2 Intake

DescriptionAll consumers referred to the Psychosis ACU complete an Intake assessment. The Intake assessment includes:

Domain 1 - symptoms:

5 Postive symptoms (the presence of something that should be absent)• hallucinations• delusions• speech and behaviour excess

5 Negative symptoms (the absence of something that shoudl be present)• alogia - poverty of speech• avolition - poverty of movement• anhedonia - poverty of expression of emotions• amotivation - poverty of initiation• affective blunting - poverty of expression of emotions

5 Disorganisation (mostly incorporated with positive symptoms)• behavioural disorganisation (impaired daily activities)

5 Cognitive (problems with thinking and speaking)• impaired attention• impaired information processing


• problems in executive functioning• thought disorder (incoherence, neologisms, loose associations)

5 Risk assessment (completing the standard CIMHA forms)• risk to self• risk to others

Domain 2 - functions:

5 intake officer documents the highest level of functioning prior to the onset of the illness

5 assessed by the Intake officer on current day-to-day activities (but generally assessed during each community visit)

5 work /educational aspects 5 social / general health.

Domain 3 - comorbidities:

5 physical ill-health (diabetes, obsesity, thyroid, cardiac) 5 illicit drug use 5 depression 5 trauma 5 anxiety 5 aggression and violence 5 criminality.

During the intake assessment the first outcome measures are collected.

ProcedureIntake ensures a consistent and co-ordinated approach to identify, assess and to provide appropriate services for consumers within the Psychosis ACU. Intake resources shall include combinations of the following and should be documented in the electronic record - CIMHA:

5 psychiatric and medical history 5 psychosocial history 5 mental state examination 5 physical examination 5 clinical risk assessment 5 case formulation and diagnosis


5 initial treatment goals and intervention plan 5 national outcome measures collection 5 psychosis ACU measures collection.

██ 2.1.3 Assessment

Description This assessment is more thorough than the intake assessment and focuses on identifying the consumer’s strengths and needs. The assessment will generally include the specialist skills of allied health and other professionals (psychology, occupational therapy, etc) who ‘add value’ to the consumers overall recovery plan. Typically, specialist assessments are organised by the case manager (Principal Service Provider) during the case review discussion.

Procedure 5 Case manager/case review generated assessments are timely, reflecting

the clinical needs of the individual consumer. Effort is made to ensure the assessment also identifies family and carer needs.

5 Current risk evaluations are conducted at assessment, and as clinically indicated in all phases of the provision-of-care. A risk assessment is also documented prior to transfer or discharge. Risk assessments include a formalised suicide risk assessment and if dependent children are present, the child harm risk assessment is completed. Should there be a prior history of harm to others, the violence and aggression and sexual harm risk assessment are completed (if appropriate).

5 Assessments are recorded using the standard CIMHA protocols. 5 Assessments of Indigenous people will include the provision of culturally-

appropriate services. In the event a consumer identifies as Indigenous, a referral will be made directly to the Indigenous mental health team/worker, to provide or participate in the initial assessment and ongoing service. A range of culturally-appropriate services and strategies are available to support the safety and integration of culturally-competent care across service settings.

5 Assessments of alcohol and drug use are undertaken with every new consumer, and routinely throughout ongoing contact with the Psychosis ACU. Detection of alcohol and drug use problems is incorporated into the treatment plan.


5 Physical healthcare assessments are routinely completed and documented. This is conducted by the medical officer or a health service provider external to the service (GP), but must be considered as part of the Psychosis ACU assessment. Documented evidence of the time, place and results of the physical health assessment will be in CIMHA. Every effort is made to ensure all consumers have a nominated GP. Consumers are actively supported to access primary healthcare for their health improvement. Potential physical health problems are identified and discussed with the GP and/or other primary healthcare provider. Where significant obstacles to accessing primary care exist, the Psychosis ACU will assist consumers to access the ED in the local public hospital to provide physical health services.

5 All mental health and other assessments are conducted in the community (if it is safe and suited to the consumers needs).

5 The outcomes of assessments are communicated to the consumer, carers and other care providers, in an appropriate and timely manner. Communication will occur on the same day for crisis assessments. For all other assessments, written or verbal communication will be conveyed in a timely manner.

5 Information regarding consumers must be shared between relevant agencies based on the needs of the consumer, and provided in accordance with established information sharing protocols and legislation. Information sharing will occur in every case unless a significant barrier arises, such as inability to gain appropriate lawful consent.

5 Family, carers and significant others will have their needs assessed and addressed as indicated and/or requested.

5 Clinicians shall be aware of the policies and guidelines on protecting children and young people (0-18 years); this is particularly relevant for consumers with severe and persistent mental health disorders responsible for dependent children.

5 Importantly, clinicians follow the mandatory requirements of Queensland Health and report to the approriate authorities any unlawful activities identified, in consultation with the Team Leader and Clinical Consultant (e.g. reporting to the police criminal activity, reporting to child safety services concerns for children or young people).


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Focus on Actions: Safety, Team CareSymptom / distress relief Focus on Recovery Goals:

Case managementRelapse preventionTreatment concordanceAdaptive functioning GP services engagedCommunity services engagedInclusion of support servicesEngage peer specialistsPeer supports / recovery groups

Focus on Integration: Provide informationLink to GP/CommunityMotivate / psychosocial

Focus on Strengths: Functional recoveryCommunity supportDisengagement

3. Stable Phase

1. Acute Phase

2. Stabilisation Phase

Diagram 5: Treatment Intervention Phases

██ 2.1.4 Treatment

DescriptionTreatment has three primary goals:

1. relapse prevention and concordance to treatment - the prevention of a relapse of acute psychosis and the associated distress

2. maximising the quality-of-life and adaptive functioning3. promoting and maintaining recovery from the debilitating effects of the

illness to the maximum extent possible.

Treatment is evidence informed and time-limited. There are generally three treatment intervention phases (Diagram 5):


1. Acute phase: Clinicians’ formulate an initial diagnosis, treatment plan and implement treatment interventions. The setting chosen for treatment will depend primarily on safety issues and on the ability of the consumer to care for him or herself and adhere to treatment. The acute phase is primarily the domain of the specialist mental health service; clinical inputs are high and contacts frequent.

2. Stabilisation phase: The aim of treatment is to stabilise the consumers symptoms, reduce the levels of distress and support their functional recovery. Interventions may not focus solely on symptom reduction, but conjointly on developing recovery skills (family psychoeducation, illness self-management, socialisation, stress management, trauma interventions, exercise, diet) and relapse prevention. During the stablisation phase the specialist mental health services, mainstream healthcare services and other services work side-by-side to optimise the consumers recovery.

3. Stable phase: The goal is to optimise functional recovery, to promote insight and understanding, to learn to detect signs of relapse, to monitor for side effects and other conditions, support social inclusion, reconnect with family, friends, culture, vocation and community. During the stable phase treatment and support is wholly transitioned from the specialist mental health service to mainstream healthcare services.

ProcedureA. Medication treatment:

General principles:

1. Medication is an essential component of a treatment plan for most consumers with schizophrenia and psychosis.

2. Psychosocial interventions work synergistically with medication to optimise treatment concordance and successful community living.

3. Medications must be individualised because the consumer response is highly variable. Consideration is given to the consumer’s presenting complaint, their response to medication, including efficacy and side effects.

4. Consumers are involved in decisions and choices for medication. This includes being provided with information on the risks and benefits of both taking and not taking medication. However, because a high level of benefit is achieved with medication, consumer concordance is assertively sought by case managers.


5. Side effect profiles are created for each consumer, and the impact upon the consumers general health is routinely recorded in CIMHA.

6. Simple medication regimes are optimised, whenever possible.

7. Dosages are maintained within the recommended range, and reasons for going outside the range are clearly justified and documented.

8. Using more than one antipyschotic is not supported by the available evidence.

9. Regular and ongoing evaluations are necesary, when the consumer responds to medication, when they do not respond to medication and when they develop side effects. Standardised scales are useful tools for baseline and later assessments.

10. The consumers GP is regularly informed and supported to eventually manage the consumers care in the community.

B. Psychosocial treatments

General principles:

1. Optimal management requires the integration of medication and psychosocial interventions. Thse interventions are complementary approaches.

2. Listening and attending to the consumer’s concerns develops empathy, rapport, and a good therapeutic relationship. As well, it can improve engagement and concordance to treatment.

3. Consumers have access to evidence-based programs that develop skills for daily living, meeting vocational and educational goals, managing finances, developing and maintaining social relationships, and coping with the impact of symptoms.

4. Psychosocial interventions are best implemented when the distress from and the impact of symptoms has been reduced; and the consumer is willing to engage in psychosocial treatment.

5. Effective psychosocial intervention often improve medication concordance, reduce the risk of relapse and the need for readmission to hospital, reduce distress resulting from the symptoms, improve functioning and quality of life, provide support for consumers, their families and carers.


6. Common comorbid conditions such as obesity, trauma, substance abuse, anxiety disorders, and depression need to be recognised and addressed with psychosocial interventions.

7. Consumers, carers and their families should be offered illness education, as well as ways to reduce the risk of relapse. It is important to provide a realistic hopeful view of the future (doctors are involved in the psychoeducation process).

8. Treatment progress is monitored and evaluated.

9. Treatment providers share plans for the early recognition of relapse and crisis responses with the consumer, carer and family.

10. The following psychosocial interventions have sufficient evidence to warrant consideration when generating the individual consumers recovery plan:

5 medication concordance and psychoeducation 5 assertive community treatment 5 integrated case management 5 vocational interventions 5 skills training (stress management, social skills training) 5 cognitive-behavioural interventions 5 family interventions 5 cognitive remediation 5 peer support, self-help and recovery.

██ 2.1.5 Recovery planning

Description It is essential every consumer has a recovery plan. Recovery plans are developed with the consumer and document ‘what is to happen now’ and ‘what happens next’.

Procedures 5 Consumers are strongly encouraged to have ownership of their recovery

plan.


5 Every effort is made to ensure that treatment care planning (recovery) focuses on the consumer’s needs and own goals.

5 Review of the consumer’s progress and planning of future goals is integrated into the recovery plan.

5 Recovery and relapse prevention planning is discussed in partnership with every consumer (and their carers if appropriate).

5 Where conflicting goals exist (e.g. for consumers receiving involuntary treatment), they will be clearly outlined and addressed in a way that is most consistent with the consumer’s goals and values.

██ 2.1.6 Continuity of Care

DescriptionClinical pathways are articulated and clear information is provided to consumers, carers and referral sources to ensure Continuity of Care exists across a 24 hour, 7 day period.

Procedures 5 Where possible, the clinician who conducted the intake assessment

becomes the case manager (PSP). 5 If ongoing care is not required after the Intake assessment, the clinician

who conducted the intake assessment will be responsible for effectively managing all associated communication (with the stakeholders and case review team). Documentation processes are to be completed within 24 hours. If referral to another clinical service is required, a follow up communication by the clinician is required to ensure linkage is successful.

5 The case manager is responsible for coordinating appropriate further assessment and care, implementing psychosocial interventions, completing healthcare checks, case review and completing referrals that lead to additional community service care and support.

5 When working with other service providers outside MSAMHS, the process for sharing information is consistent with Queensland Health policy and explicitly documented by the clinician.


██ 2.1.7 External Transfer of Care

DescriptionExternal transfer -of -care (previously referred to as ‘discharge’) shall comprehensively incorporate:

• information sharing• relapse prevention• crisis management• clearly articulated service re-entry processes.

Procedures 5 Comprehensive liaison and handover occurs with all other service

providers who are or will contribute to the consumer’s ongoing care. 5 Ongoing service providers are involved in transfer planning. 5 Consumers are encouraged to actively contribute to and to counter-sign

their transfer plan. 5 Clinicians are responsible for ensuring transfer letters are sent to key

health service providers (e.g. GP) on the day of transfer. 5 Service exit letters need to be comprehensive and indicate:

• diagnosis, treatment provided, progress of care• recommendations for ongoing care• procedures for re-referral.

5 Relapse patterns, risk assessment and risk management information is provided to consumers, family and carers as clinically indicated.

5 A follow-up direct contact with ongoing key health service providers (e.g. GP) will occur to ensure the transfer information was received and the service provider agrees to the provision of ongoing care.

5 Where possible, family/carers will also be directly involved in transfer planning.

5 Where consumers are lost to follow-up, there will be documented evidence of attempts to contact the consumer, family/carers and other service providers before the record is closed to the Psychosis ACU.


██ 2.1.8 Internal Transfer of Care

DescriptionDisengagement by the Psychosis ACU will not occur before the receiving ACU has made contact with the consumer and scheduled a first appointment.

Procedures 5 The policy and procedure for internal transfers guide transitions (receiving

ACUs will make strenuous efforts to establish contact within a reasonable time period for all involved).

5 The time period will be individually determined at a local level between the Psychosis ACU and the receiving service/s.

5 A verbal handover is provided on every transfer occasion (often doctor to doctor).

5 A timely written handover (SHARE FORM) is provided on every transfer occasion.

5 CIMHA documentation supports the Transfer of Care and records the communications undertaken.

5 Consumers and their family/carers are informed of transfer procedures.

██ 2.1.9 Partnerships

DescriptionStrong private partnerships are initiated and maintained with local health and other mental health services and also service providers from government and non-government agencies.

Procedures 5 Case managers work in close collaboration with other health-related

service providers to meet the individual consumer’s needs. 5 Assistance is offered to local government and non-government agencies

to assist with the consumer’s recovery and social inclusion (e.g. return to work programs, vocational training, further education and training, housing, etc).


5 Advice, education and support shall be provided to other service providers (with the consumers consent).

5 Advice and strategies are provided to shared-care workers on how to identify and manage the symptoms of psychosis (relapse prevention program).

5 When more than one service provider is involved in service delivery, the case manager will initiate and participate in discussions around which service will adopt the role of lead agency.

5 The Mental Health Service Integration Coordinators (SIC) shall work collaboratively with case managers to engage other government agencies in the provision of required services.

5 A strong partnership will be initiated and maintained with other state and federal government agencies; including Centerlink, Housing, Police, Ambulance and Medicare Locals. The case manager shall promote: • joint private planning and decision making• shared care (with GPs, other mental health providers, NGOs, ATAP

providers, etc)• utilise an exchange of knowledge and expertise• enhance communication.

5 When consumers have specific needs (e.g. sensory impairment, transcultural) to ensure effective communication, the case manager shall engage the assistance of the appropriate services. Certain population groups require specific consideration and collaborative support. This includes people from Culturally and Linguistically Diverse (CALD) backgrounds and Aboriginal and Torres Strait Islander people.

██ 2.1.10 Working with carers and families

DescriptionFamily/carers/significant others are involved in the consumers recovery as much as possible. Significant effort must be made to support this involvement.

Procedures 5 The consumer’s and/or guardian’s consent to disclose information and

to involve family/carers in the recovery plan, is sought in every case (and documented on CIMHA).


5 Information sharing, with family and carers, occurs for every case unless a significant barrier arises, such as inability to gain appropriate lawful consent.

5 Family and carers informed consent is also documented in the consumer clinical record (CIMHA), detailing that they understand the recovery plan and agree to encourage and support (if appropriate) the provision of ongoing care to the consumer in the community.

5 The needs of families, carers and significant others must be routinely addressed by the case manager.

5 Children of parents with a mental illness are routinely considered as part of all assessments, and interventions with support provided / facilitated if needed.

5 All consumers are offered information and assistance to access local peer and other support services. Peer support services may be provided by internal or external services. Consumer consultants and peer support workers are accessible via the local mental health service.

██ 2.1.11 Team approach

DescriptionThe treating team, the Multidisciplinary Team (MDT), is accountable and shares the responsibility for the care of the consumer with the case manager.

Procedures 5 Clear clinical, operational and professional leadership is provided within

the MDT. 5 The assessment, treatment and intervention services are delivered

by the MDT - the case manager coordinates and delivers services as recommended and supported by the treating team.

5 The consumer and family/carers are informed of the MDT model. 5 Case coordination is managed to ensure effective use of resources and to

support staff to respond to each presentation in a timely, effective manner. 5 Discipline specific skills and knowledge is utilised as appropriate in all

aspects of service provision (medical, psychological, social work, etc).


██ 2.1.12 Clinical review

DescriptionClinical cases are discussed at the clinical review meetings, which are held weekly. Case managers must attend the case review meetings, chaired by the consultant psychiatrist.

Procedures 5 A consultant psychiatrist will be in attendance at all case reviews. 5 A case review will provide an in-depth review and follow a set agenda.

All clinical discussion and notes from the review will be recorded in the clinical file and the consumer care review summary.

5 First presentations, ongoing assessments, treatment and intervention plans, and significant changes in the consumer’s healthcare status are regularly and routinely discussed at the MDT case reviews.

5 All case review discussions are documented in the CIMHA record. Details of the initial case review will include the consumer care summary (clinical issues raised, assessment and treatment care plan, and those responsible for completing the designated actions).

5 Changes in treatment are discussed by the team and actions are agreed to, assigned and recorded in the clinical record.

5 Ad-hoc case reviews will occur to address complex clinical issues and following a critical event.

5 Critical events will be reviewed utilising the clinical incident management implementation standard.

5 Consumers with high risk, crisis presentations and unstable needs are to be discussed by an ad-hoc clinical review team daily.

5 Consumers who are stable, not high-risk and have a clear treatment plan are discussed within 90 days.

5 Any changes to the treatment intervention plan will be done in collaboration with the consumer (changes and recommendations may arise from the case review process, but should be implemented with the consumers cooperation).

5 Every consumer’s progress and their outcome measures will be regularly monitored (case managers are to routinely collect the outcome measures information).


██ 2.1.13 CIMHA

DescriptionCase managers are to enter and review all required information into the Consumer Integrated Mental Health Application (CIMHA) in accordance with the approved statewide and district business rules.

Procedures 5 All consumer clinical information will be entered on CIMHA. 5 All referred and open consumers will have a designated PSP (case

manager). 5 All open consumers will have a designated consultant psychiatrist. 5 Personal and demographic details of the consumer, their carer/s and other

health service providers must be regularly reviewed and kept up-to-date. 5 Progress notes will be consecutive within the clinical record according to

date. 5 Case managers are to utilise the routine outcome measure mandated

through the National Outcomes and Case mix Collection (NOCC) as part of their assessment, recovery planning and service development. The outcome measures are discussed on entry and exit from the Psychosis ACU. Routine outcome data is utilised, where clinically indicated at all formal case reviews and will be an item agenda on the relevant meeting agendas. Results of routine outcome data will be discussed with consumers and their carers. Routine outcome data is discussed with consumers to record details of the consumers’ symptoms and functioning, monitor changes in symptoms and functioning.

5 Clinical records will be kept in accordance with legislative requirements.


██ 3.0 IntroductionWhere Part 2 focused on those activites related to the consumers community care, Part 3 describes the core elements associated with the system-of-care. There is obvious cross over between Parts 2 and 3, however the essence of Part 3 is it’s relevance to operational outcomes.

██ 3.1 Hours 5 While some variation may occur, routine assessments and treatment

interventions are generally scheduled between the hours 8.30am and 4.30pm (Monday to Friday).

5 Outside normal business hours services are provided by the RAS ACU (MH CALL, Acute Care Team, Hospital EDs).

5 A MSAMHS consultant psychiatrist is rostered on-call and accessible after hours.

██ 3.2 WorkforceThe size of the workforce is determined by the size of the community affected (number of open ACU consumers). The workforce is based on:

5 A multidisciplinary staffing profile that incorporates the skills of nursing, psychology, occupational therapy, social work, peer support workers, vocational support officers and medical officers (psychiatry). The proportion of disciplines may be locally determined, within the guidelines of relevant policy and funding restrictions.

Part 3: system-of-care





5 A consultant psychiatrist is accessible for urgent consultation 24 hours, 7 days a week (outside of business hours the on-call consultant is the point of access).

5 Medical representation occurs at all clinical case reviews, multidisciplinary team reviews and ad hoc and/or formal case reviews.

5 Clinical staff deliver both specialist discipline-specific assessments and interventions, in addition to their primary role of case management.

5 Administrative support is provided to all teams. 5 Permanent experienced clinicians are appointed (or working towards

becoming) authorised mental health practitioners. 5 Linkages between clinicians and existing providers of mainstream mental

health services are maintained in order to provide continued care to consumers, and also to capture consumers who are delayed in re-entering the service.

██ 3.3 Roles and responsibility

Team leader Core tasks:

5 team leadership, service development and management 5 service and operational leadership (operationalising strategic priorities) 5 service integration and partnership development with key stakeholders 5 performance review of non-medical staff 5 analysis and reporting on clinician and service activity for team 5 organisation and team culture 5 operational management of the day-to-day functioning of the team 5 delegation of daily clinical responsibilities within the team 5 quality, human resource management, workplace health and safety.

Consultant psychiatrist/registrars Core tasks:

5 medical leadership and clinical direction 5 best practice and service delivery monitoring


5 service delivery innovation 5 direct and supervise the medical management of consumers 5 provision of the medical services 5 direct clinical assessment and treatment / intervention 5 lead agent for all case reviews 5 lead clinical integration with other relevant clinical specialities 5 lead education and up-skilling of clinical team members 5 completion of service activity data (CIMHA records).

Clinical staff Core tasks:

5 case management (guided by Psychosis ACU framework) 5 intakes, full assessments, treatment planning/intervention and case

management 5 meet case review expectations and standards 5 lead consumer and carer advocacy, participation and involvement 5 completion of outcomes and service activity data (CIMHA records) 5 attend inservice education, supervision and performance reviews.

Discipline-specific roles Core tasks:

5 Discipline specific skills are utilised to ensure comprehensive assessments of consumers occur. Profession-specific skills are also used when determining and undertaking a particular type of intervention, level of service or the most appropriate member of the team to case manage a consumer.

5 The MDT is supported by administrative officers who assist clinicians with the day-to-day operations of the Psychosis ACU.

Generic role elements 5 Clinicians hold a current Queensland Drivers licence. 5 Clinicians hold a current registration with their respective professional

bodies or credentialing requirements (if required). 5 Clinicians are Authorised Mental Health Practitioners under the Mental


HealthAct2000, or eligible for authorisation. 5 Clinicains embrace safety, quality improvement and goal directed change. 5 Clinicians have access to training opportunities delivered by Queensland

Health and MSHHS. 5 Clinicians are required to engage in formal professional supervision on a

monthly basis. 5 Clinicians attend a monthly catch up with the team leader to review their

case list, discuss potential closures and discuss practice issues. 5 Clinicians attend and present at regular in-service programs. 5 Clinicians submit leave requests to the team leader. 5 Clinicians attend mandatory annual training in Fire, Aggressive Behaviour

Management, Infection Control and Basic Life Support. 5 Clinicians have a current Professional Appraisal Development (PAD). 5 Clinicians access policies and work unit guidelines on the QHEPS and

METSPEN intranet sites.

██ 3.4 LeadershipLeadership is the ability to provide direction and cope with change. It involves implementing a service vision, developing strategies for producing the changes needed to realise the vision, and aligning staff and motivating and inspiring staff to overcome obstacles in pursuit of the vision.

Leadership within the Psychosis ACU is based on staff capability rather than profession; there is healthy debate and collaboration with a focus on team rather than on the individual professions.

Key tasks include:

5 ensuring principle-led and value-based work practices are clearly evident 5 creating a method that encourages and supports staff to contribute to

making the work practices happen (in pursuit of the vision) 5 sponsoring regular information and communication meetings, structured

orientation, training and education programs 5 esuring the right people are doing the right work; without duplication of

services 5 articulating that intentional breaches of relevant policies and procedures

are not tolerated 5 ensuring adverse events are disclosed and investigated and lessons are

learned and applied


5 influencing work practices through their statements, actions, staff supervision and responses to circumstances and events

5 supporting and encouraging staff to provide quality care; the expectation is that staff will work within an agreed scope of clinical practice

5 implementing policies, procedures, role descriptions and associated documentation to create a clear framework to allow each staff member to understand their roles and responsibilities and the expectations that apply regarding service outcomes, safety and quality

5 being responsible for conveying consistent work practice and workplace expectations (staff know what to do, when, why, how and where)

5 ensuring performance appraisals and supervision activities are current.

██ 3.5 GovernanceThe following outlines a broad clinical governance structure for the Psychosis ACU:

1. Staff structure

5 The Psychosis ACU is comprised of MDTs located in the Princess Alexandra, Redland and Logan hospital catchment community settings.

5 Local teams have a designated team leader and consultant psychiatrist to provide governance within their delegation. Key responsibilities include:• Within the team, the team leader will provide operational governance.• The consultant psychiatrist will provide and be responsible for clinical

governance. • These position holders will establish a strong collaborative working

relationship. • Clear clinical, operational and professional leadership is established

and communicated to all internal and external stakeholders.2. Service components

5 specialist community care pharmacological and psychosocial treatments 5 case management 5 outreach service provision 5 in-reach to acute inpatient services.

3. Service linkages

5 The Psychosis ACU has established service pathways with specialist mental health programs and services including addictive services, CALD and Indigenous.


5 The Psychosis ACU operates with established service pathways to local primary care services and government and non-government services, community-based programs (peer support services) and networks.

4. Support components

The Psychosis ACU is supported by:

5 Assessment and management processes (e.g. Statewide suite of clinical forms) that meet best practice and service requirements.

5 Established referral systems between and within other relevant services and programs.

5 Clinical handover systems, monitoring and reviewing processes that promote multidisciplinary collaboration and team decision-making both within the Psychosis ACU team and across the mental health service.

5. Staff support

Staff are supported by:

5 appropriate models of clinical supervision 5 discipline specific training and education, professional development, peer

review and supervision 5 staff credentialing processes 5 education and training sessions.

6. Quality program

Quality processes include:

5 multidisciplinary clinical review and audit programs 5 periodic and ongoing outcome analysis 5 review of all adverse events and critical incidents 5 consumer and staff surveys 5 staff evaluation and performance appraisals 5 staff development and training opportunities 5 budget reviews 5 development and review of procedures and work instructions 5 processes for identifying and managing risks that link to the mental health

service risk management plan 5 staff safety procedures that cover clinical emergencies, working in isolation,

home visits, critical incident management, infection control procedures and other relevant matters.


Records management

Record management systems that support govrenance include:

5 informed consent and consumer rights systems in accordance with the relevant legislation

5 clinical documentation processes, policies and procedures 5 statewide suite of clinical forms 5 clinical information technology systems (entering information on CIMHA) 5 the National Outcome Measures 5 secure information exchange systems 5 information transfer services (between agencies and practitioners).

██ 3.6 Case loadThe size of a clinician’s case load takes into consideration a range of factors, including:

5 complexity of the consumers need 5 diagnosis 5 local population and demography 5 size of the particular team 5 skills and experience of the particular clinician 5 capacity for clinical supervision and support 5 the needs and function of other mental health teams in the district.

In the event individual case loads exceed the capacity to provide optimal care, a review of all factors that influence case load is conducted by the clinical and operational leaders.

██ 3.7 Consumer engagementEngagement is a systematic ongoing process that actively engages the consumer in their own care and treatment, and where appropriate, encourages the participation of carers.

Engagement ensures consumers and their carers are:

5 aware of their rights and responsibilities


5 informed about their treatment and healthcare 5 actively involved in decision-making processes 5 certain their information is treated in accordance with the legislative

requirements covering consent, privacy and confidentiality.

The purpose of engaging consumers and carers is:

5 to encourage and obtain consumer (family and carer if appropriate) participation in their care and treatment

5 to support healthy relationships between the consumers and their family and carers.

The range of key activities in relation to consumer engagement include:

5 informing and collaborating with consumers about the process of assessment and care coordination.

5 providing access to support services (e.g. interpreter services), materials and information promoting culturally sensitive practice

5 with the consumer developing and implementing assessment and care plans.

██ 3.8 Sector engagementSector engagement is a crucial component of the MSAMHS strategy. Sector engagement is an ongoing assertive process that initiates the process of shared care or the transition-of-care to other specialist mental health services or the mainstream healthcare and other related services. As such, sector engagement aims to:

5 build and maintain service pathways, networks and effective working relationships to enhance access and entry to the right services

5 establish common consumer (carer and family) and service goals 5 determine and develop agreed methods of shared communication and

service coordination 5 conjointly identify, manage and resolve service difficulties and conflicts

and achieve positive consumer outcomes 5 gather, convey and receive service information, knowledge and ideas 5 collaborate on policy and future program development.

Sector engagement is about promoting ‘Continuity of Care’ (the consumer experiences a seamless system-of-care).


Key internal MSAMHS relationships include:

5 1300 MH CALL. 5 Acute Care Team (ACT) 5 acute inpatient units 5 other ACUs 5 service integration coordinators 5 Homeless Health Outreach teams 5 primary care coordinators 5 transitional housing team 5 Indigenous mental health services 5 forensic mental health services 5 police mental health liaison officer.

Key external (specialist and mainstream healthcare) relationships include:

5 hospital EDs (Princess Alexandra, Logan, Redlands, Bueadesert) 5 emergency services (e.g. Queensland Health, Queensland Police Service,

Queensland Ambulance Service) 5 primary care providers (e.g. GPs, community health services, Medicare

Locals/private practitioners (ATAPS)) 5 government and non-government organisations (e.g. Centerlink,

Anglicare, Lifeline, Relationships Australia) and other community support services (e.g. peer support programs)

5 vocational and educational services 5 faith-based and cultural services.

██ 3.9 Supervision Clinical supervision is the most appropriate learning medium for the clinician because it is a ‘learning by doing’ process rather than a distant, classroom type of experience. Supervision provides clinicians with a facilitated, ongoing assessment of their skills and areas of clinical strengths and weaknesses. Clinical supervision is distinct from operational supervision. Operational supervision is about adherence to workplace policy and procedure, quality and safety and performance.

In line with clinical governance, it is essential that there is a well-defined and robust system of clinical supervision within the Psychosis ACU.


The purpose of supervision is to support professional development, while ensuring skills and competencies meet the needs of consumers.

The range of key supervision activities include:

5 completing regular supervision sessions 5 identifying learning and training objectives 5 resolution of conflict (arbitrator identified) 5 identifying roles and responsibilities 5 specifying workplace practicalities (e.g. supervision location, supervision

practices, etc) 5 identifying boundaries (e.g. time and agreed supervision agenda) 5 identifying the documentation to be used 5 specifying confidentiality (adherence to a professional code of conduct

and Queensland Health policy) 5 specifying key actions in the event of non-attendance or cancellation 5 identifying frequency and duration of the supervision sessions.

Resources that support supervision include:

5 supervision contract 5 supervision record.

The expected supervision outcomes are:

5 At the start of employment the supervision process is made clear to all new staff members.

5 Supervision is included in the role description. 5 Emergency adhoc supervision is available in times of crisis. 5 Clinical supervision occurs at a minimum of once every two weeks, or

more frequently, as per professional body guidance. 5 The team leader has a clear system of monitoring and auditing clinical

supervision. This is to be reviewed every six months. 5 The Psychosis ACU has clear clinical supervision guidelines which

incorporate supervision contracts between the supervisor and supervisee. 5 Supervision adheres to a specific structure (relevant to the appropriate

professional body) and also addresses both clinical and managerial factors.

5 Supervisors receive/have the appropriate training.


Good supervision occurs when:

5 Supervision reviews key consumer and carer outcomes (e.g. satisfaction). 5 Supervision monitors the quality of the supervisees work practices across

the continuum-of-services and supports. 5 The quality of the supervision sessions are regularly monitored and

reviewed. 5 Supervision develops the core skills and training needs for the supervisee. 5 Supervision guides self-development. 5 Supervision supports the supervisee in stressful situations.

██ 3.10 TrainingStaff are provided with continuing education opportunities, mandatory training, clinical supervision and other support mechanisms to support their learning and clinical competence. All training is based on best practice principles, evidence-based treatment guidelines and underpinned by the QueenslandGovernmentCodeofConductand workplace values.

Access to education and training includes (but will not be limited to):

5 CIMHA (including clinical forms training) 5 mental health assessment 5 clinical risk assessment 5 de-escalation training 5 aggression behaviour management5 MentalHealthAct2000. 5 alcohol and drug assessment and interventions 5 clinical and operational skills/knowledge development (including mental

health generic and discipline-specific training needs) 5 medication and side effect management 5 consumer-focused care planning 5 routine outcome measurement training 5 cultural-capability training.


██ 3.11 DocumentationThere is no ‘single source of truth’ - clinicians are aware that there is always likely to be other consumer clinical records that contribute to the overall clinical record. Clinicians should also be aware that electronically signed clinical notes information entered in CIMHA is the legal version of the note and the unannotated printed versions are copies only.

The availability of any source of information about a consumer does not obviate the requirement for comprehensive clinical history taking and the need for clinicians to access a wide range of information sources about the consumers under their treatment or care.

Accuracy

To be an accurate clinical record, documentation should include:

5 clinically-relevant interactions 5 clinical event (what occurred, when, why, how managed, who involved) 5 history of event (e.g. assessment and treatment interventions etc) 5 changes in behaviour or healthcare status 5 adverse events (e.g. self harm, suicide attempts, violence) 5 direct reporting (e.g. consumer questions, statements and information

provided as it happened) 5 indirect reporting (e.g. heresay reported as such).

The clinician who is directly involved with the consumer/carer or who witnessed the event or has direct knowledge concerning the case record writes the clinical report and case records (case records are not written on behalf of a colleague base on handover information).

Accuracy is further enhanced when case records are completed immediately after the event (e.g. mental state examination). Records that are written hours later or the next morning are likely to have their accuracy questioned.

The time and date of each entry should be noted in the record next to the entry (the time and date of the event should be recorded separately). For example, in the event where notes are written at a later time it is preferable to record the date and time that the notes were made while making it clear in the notes the time of the event being written about.


Objectivity

When writing in clinical records, avoid making subjective statements about the consumer or their circumstances, it is better to document observations rather than subjective assessments.

Clinical opinion, recorded as ‘opinion’, should be supported by the recording of objective data that gave rise to that opinion.

A clinical record should always be written using the language of the professional, without negativity and without criticism of others. Sometime in the future the consumer (or their carer) may read your clinical note. Always write with the potential reader in mind.

Legibility

Documentation is of little value if handwriting cannot be understood by other clinicians. Misinterpretation of handwriting can lead to significant error in care.

Abbreviations should be avoided unless they are widely used and known in the health industry (Queensland Health has an abbreviations policy and list of acceptable abbreviations and clinicians are to make themselves aware of this policy).

Formatting details

Each entry should:

5 be written in consumer focused or person centred language 5 be written in black ball point pen (not ink or pencil) 5 include the date and time (in 24 hour clock) usually in the left hand margin 5 be signed with your name and designation (eg RN, RMO, Psychologist)

clearly printed below the signature.

Making amendments

If an amendment must be made it is preferable to:

5 put a neat line through the entry (the original entry must remain legible), add a note in the margin stating why the amendment has been made and initial the change

5 add the correct entry and sign 5 never delete material by scratching it out, covering with correction fluid or

typing over it


5 all clinicians must ensure that they are documenting to a standard that will ensure the best outcome for their mental health care program and for medico legal accuracy, but above all, for the continuing optimum care of their consumers.


Part 4: aPPendix

██ 4.0 Assessment measuresIntroduction

The information provided establishes the assessment measures clinicians are advised to collect. This information brings together evidence from a range of sources, including academic literature and research, current service practices and proposals, and people’s own experiences to address the service expectations identified in the National Standards for Mental Health Services (2010).

The aim is to improve service outcomes and to deliver services in a more individualised way, more efficiently. This is true of clinicians where they seek to improve the way their services work so that more personalised, evidence-based and effective service is delivered in a more cost-effective way.

Getting started

The crucial first step is to explain to the consumer the purpose of the assessment, bearing in mind the consumer would already have undergone a full mental health assessment.

This assessment will supplement the information gathered and documented already; it should not replicate current information reported in the clinical file, unless it is to further clarify an event, circumstance or issue.

The aim of this first step is to identify the consumer’s needs and concerns, and to prioritise what is to happen next.

The consumer is informed that certain measures are to be used to help construct the treatment and recovery plan (the clinician may complete these with the consumer at this time or, alternatively, the consumer completes





them in their own time and they are collected during the next session). The primary goal of assessment is to clarify the consumer’s needs and concerns, to prioritise these and to develop a practical action plan. Clinicians tailor their assessment to obtain the information sought. Obviously, if clinical information is absent from the clinical record – then the clinician completes a full mental health assessment (using the routine CIMHA forms).

In most cases, the assessments are completed in approximately 40-60 minutes.

Collection protocol

This collection protocol guides the Psychosis Academic Clinical Unit clinicians to collect the relevant outcomes information, including the standard information currently collected on the consumer (NOCC on CIMHA).

The outcome measures identified and this protocol represent a deliberate emphasis on the collection of quality clinical information. It recognises the need for compliance, as clinicians direct their efforts toward the collection of measures information that will inform consumer treatment planning and decision-making.

This collection protocol is for all Psychosis ACU clinicians. The purpose of the collections (outside the scope of the standard mental health outcomes collection) is to:

5 deliver to the clinician and consumer time-dependent comparative information (pre, during and post-treatment intervention) in order to provide an understanding of change in the consumer’s health status

5 deliver case complexity information to guide case planning 5 provide treatment information required by the Activity Based Funding

(ABF) program.

Collection occasions

A collection occasion is defined as an occasion when the outcome measures and the case complexity information are collected in accordance with the collection protocol. There are three collection occasions:

1. Beginning-of-care collection: marks the commencement of the Treatment Service Episode. This collection denotes the complete collection.

2. Mid-collection: occurs every 90 days and repeats the previous collection.

3. End-of-care collection: occurs when the Treatment Service Episode is closed.


The specific collections occur for all adult consumers, irrespective of the service delivery provided.

Collection methods

The following tables summarise the measures and clinical information to be collected. In general, the measures and clinical information collected will be used for the purposes of guiding the development of the treatment plan, as well as outcome evaluation and case complexity. Measurement of outcomes requires information to be collected from the Beginning-of-Care and End-of-Care collections to allow for an assessment of change overtime.

Essential measures (completed for all consumers)Mental Health Inventory (MHI) Consumer measureHealth of the Nation Outcomes Scale (HONOS) Clinician measureLife Skills Profile - 16 (LPS16) Consumer measureClinical Global Impression (CGI) Clinician measureBrief Psychiatric Rating Scale Clinician measureAbnormal Involuntary Movement Scale (AIMS) Clinician measureIdeopathic Measure - SUDS Consumer measure

Preferred comorbidities measures (completed for most consumers)Short Form 12 Health Survey (SF12) Consumer measureAlcohol Use Disorders Identification Test (AUDIT 6) Clinician measureKessler 10 (+ 4) Consumer measureSocial and Occupational Functioning Assessment Scale (SOFAS)

Clinician measure

Dimensions of Psychosis Symptoms Severity Clinician measurePost Traumatic Stress Disorder Checklist (PCL-C) Clinician measure

Essential measures are collected from all consumers, while preferred measures are collected from those consumers who have or may have comorbid conditions. All collections are summarised and reported on CIMHA and to the case review team.


██ 4.1 SummaryThe Psychosis Academic Clinical Unit delivers adult, whole-of-community care to:

5 people 18 years to 65 years 5 people with an acute psychotic or schizophrenic illness

Referrals are primarily from the RAS and Inpatient ACUs.

Assessment and treatment prioritises people with ‘acute care’ needs. Service delivery is outreach and targets community care. Inpatient care is also provided.

The Psychosis Academic Clinical Unit service framework focuses on three clinical domains:

1. consumer distress and symptom relief

2. consumer functioning, and

3. consumer comorbidities.

Service delivery is structured around a broad biopsychosocial approach, providing:

5 management of illness and symptoms (guideline compliant treatment) 5 guidance and practical assistance with daily living 5 care and rehabilitation 5 recovery support and working with support systems in the family, general

practice and local community.

The Psychosis Academic Clinical Unit is a multidisciplinary team that provides or coordinates these services.

Metro South Addiction and Mental Health Services

Psychosis ACU Model of Care, November 2014 to June 2016

Version 1, created November 2014.

For further information please contact:

Metro South Addiction and Mental Health Services

PO Box 6046, Upper Mount Gravatt Qld 4122

t: +61 7 3339 4623

e: [email protected]

www.health.qld.gov.au/metrosouthmentalhealth

This document is licensed under a Creative Commons Attribution Non-Commercial 3.0 Australia licence. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/3.0/au/

Copyright © State of Queensland, Metro South Hospital and Health Service 2014

You are free to copy, communicate and adapt the work for non-commercial purposes, as long as you attribute the authors. Preferred citation: Metro South Addiction and Mental Health Services , Queensland Government, Brisbane.

Disclaimer:

ThecontentpresentedinthispublicationisdistributedbyMetroSouthAddictionand Mental Health Services as an information source for specific cliniciansonly. It is intended as a service provision guide, as such the Metro SouthAddictionandMentalHealthServicesmakesnostatements, representationsorwarrantiesabouttheaccuracy,completenessorreliabilityofanyinformationcontainedinthispublication.MetroSouthAddictionandMentalHealthServicesdisclaimsallresponsibilityandallliability(includingwithoutlimitationforliabilityinnegligence)forallexpenses,losses,damagesandcostsyoumightincurasaresultoftheinformationbeinginaccurateorincompleteinanyway,andforanyreasonreliancewasplacedonsuchinformation.

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