Prepared by Dr Martyn Patfield Mental Health Emergency Care – Rural Access Programme

1. 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

2. 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 available…via video technology And therefore… Safer and better quality care Less inappropriate transportation to inpatient units Improved mental health skills in general ED staff

3. 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.

4. Admissions to Orange Psychiatry inpatient unit, 1990 - 2006

5. 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…………. Strategic importance

6. 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

7. 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.

8. 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.

9. 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.

11. Transport to Inpatient Unit vsTendencyto use MHEC RAP

12. 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

13. GWAHS Map –MHEC-RAP Training Sites • 08-09 Sites where training was conducted • Future sites Coonabarabran Wilcannia Warren Balranald

14. 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 key…but can they be measured?) People – It’s the staff that makes it work, not the machines

15. Photo of team

16. 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.

17. Presentations at A&E – Behavioural Types First 18 months. Triages Aggression 231 7% Threats Suicide/ DSH 1373 42% Confused/Psychotic 672 20% Anxiety/depression 689 21% Intoxication/ D&A 48 1.5% Other 206 6% TOTAL 3219 16

18. Patient Interview Numerical Responses(First year evaluation report, University of Sydney)