Clinical Management in Mental Health Services

Document NumberCHHS13/347

Mental Health Justice Health Alcohol and Drug Services (MHJHADS)

Standard Operating Procedure: Clinical Management in Mental Health Services

Purpose

The National Standards for Mental Health Services 2010 state that care management is a cyclical process, in which needs are assessed, services are delivered in response, and needs are re-assessed, leading to a changed service response.

Scope

This Standard Operating Procedure applies to all staff employed in a clinical capacity in all Mental Health services, including community mental health settings. The principles of evidence based practice (Clinical Practice Guidelines; psychological interventions; pharmacological interventions) will be used to support people during their episode of care. An allocated medical officer will have a clinical leadership role with all clinically managed people.

Procedure

Background

When clinically indicated, Mental Health provides services using a clinical management [CM] framework to consumers across the age span during an episode of care. Within this framework, Mental Health services clinicians provide a comprehensive and collaborative assessment which is summarised in a formulation with an interim clinical plan, engagement in collaborative recovery planning, care coordination and therapeutic interventions inclusive of psychological therapies. Standardised clinical processes are defined for case review and clinical handover for transfer of care and/or episode of care closure.

Mental Health services is a personcentred service that promotes a collaborative approach with other service providers and agencies. Mental Health services aim to foster independence for people experiencing mental disorder or mental illness to promote wellbeing and autonomy to support ongoing recovery.

The recovery principles for Mental Health services (see at Attachment 1) and the Recovery Standard of the National Mental Health Standards (see at Attachment 2) guide this approach to care and are applied in Mental Health services within the context of standardised clinical processes.

Roles & Responsibilities

Consistent with The National Standards for Mental Health Services 2010 (NSMHS), 10.3.8, at the point of entry, a nominated clinician is allocated as the primary point of contact for all stakeholders related to the person’s care. Within Mental Health services, the nominated contact point for requests for medical consultation with a consultant psychiatrist is the administrative officer.

Team Leaders, Operational Directors and Clinical Directors ensure that processes are in place in all teams to support the provision of clinical management. These processes encompass, but are not limited to: multidisciplinary team meetings, clinical review, allocation of people and clinical handover.

Relevant Policies, SOPs and the Clinical Processes and Documentation Resource Package V4 (2011) outline the processes and define the expectations of CM. The determination to provide CM is made by the multidisciplinary team inclusive of medical leadership. The interventions provided [psychological - inclusive of psychosocial and family interventions - and pharmacological] are to be evidenced-based and consistent with the Royal Australian & New Zealand College of Psychiatry (RANZCP) Clinical Practice Guidelines.

Clinical Management also acknowledges the importance of a holistic approach to support people in their mental health recovery and for this reason values the contributions of the multidisciplinary team including non-clinical support staff, peer workers and community agency staff. Interventions to address ongoing functional difficulties, strategies to address obstacles to social inclusion and harnessing adequate supports and resources may be required to assist the person’s ongoing recovery. Clinical Managers will have some core and specialist skills to inform appropriate interventions to assist in these areas and it is anticipated that Clinical Managers would also refer to, and collaborate with other rehabilitation and support services as required.

Mental Health services have a range of strategies to support clinicians, including daily clinical meetings, scheduled case reviews, clinical and operational supervision and professional development/training.

General Practitioners [GPs] are an integral part of the treating team and Clinical Managers will liaise with GPs within structured timeframes such as initial assessment and three monthly reviews as well as ad hoc contact in the event of any change in treatment or identified deterioration of people’s mental health.

The scheduled three monthly review is a flag for Clinical Managers to regularly review the outcomes of interventions and liaise with all stakeholders. The completed Case Review form, Outcome Measurement/s, progress in psychological therapy, response to pharmacological treatment, considerations for rehabilitation and/or ongoing recovery will be discussed at these reviews.

Planning for discharge is an ongoing discussion and takes into account the needs and perspectives all stakeholders. Early recognition of deterioration and Keeping Well Plans will be developed as a component of discharge planning.

If re-contact with mental health services results in a decision to re-commence CM, the previous Clinical Manager will be re-allocated if capacity exists.

Triaging, Intake & Referral and Screening Guidelines

Entry refers to the process by which the mental health service assists the person and their carers to make contact with the mental health service and receive appropriate assistance.

Mental Health services have multiple sites of entry with a single process that is consistent across the ACT. When a person first makes contact with or is referred to Mental Health services, a clinician will undertake an assessment. This assessment will include an overview of the person and their situation inclusive of an assessment of the level of risk. The presentation and the level of response required is informed by the Mental Health Triage Scale (2010; See at Attachment 3).

All assessment documents generated on MHAGIC will include the completion of the response category section of the document. Response categories are allocated according to the level of risk assessed at presentation.

Additionally, Screening Guidelines for Mental Health Services (see at Attachment 4) are provided to support cliniciansin referral of persons to facilitate their access to optimal, appropriate care. The guidelines also provide referral options to other agencies where specialist mental health interventions are not indicated, or to identify potential partners to provide coordinated care where specialist mental health services are indicated.

Process of case allocation

Clinical Management must be considered for all clients who are identified as having high vulnerability or risks, complex and long-term needs. When there is a determination that an individual is to be provided clinical management, the Team Leader will monitor all referrals and ensure that people’s allocations for CM occur in a transparent, equitable and sustainable manner matching the person’s needs to clinician skills and knowledge.

Caseload size for CMs will be based on a matrix inclusive of: complexity (e.g. considering factors such as comorbidity of other mental and physical health, substance use issues, social/occupational functioning); acuity (e.g. intensity of contact required, as reflected by the frequency and duration of Occasions of Service); diagnosis; focus of care and the phase of engagement (e.g whether CM is in the initial 6 months or longer), recognising that this period of engagement often requires a higher level of intensity; number of people on the clinician’s existing caseload; and skill setand level of experience of the staff member.

The following guide should be adapted to the clinician’s employment status {FT or PT] and additional formal roles and responsibilities. This figure is not intended to ‘cap’ caseloads but along with the above matrix is monitored in meetings between the Team Leader and clinician. The team-based monthly reports generated from MHAGIC will be used to support this process.

Case load allocation can be expected to be within the following range:

Designation / Case load allocation
HPO1 / RN 1 / 10 to 15 persons
HPO2 / RN2 / 20 to 25 persons
HPO3 / RN3 / 25 to 30 persons (to include consumers with complex needs)

“Doctor-only” Managed Clients

It is acknowledged that some people may require some degree of ongoing contact with Mental Health services yet not require the additional support and resources associated with clinical management.

In such cases, a person may remain primarily under the care of a Consultant Psychiatrist with minimal, if any, support and contact from other clinicians within the community mental health team. The interventions for such people may be limited to periodic review by the Consultant Psychiatrist, and as a general rule they should only require review every 3 months or more. For people who require more frequent contact, consideration should be given to referral for clinical management.

Additionally, where there is an identified marked deterioration in a person’s mental state, the treating Consultant Psychiatrist should refer the consumer to the Multi-disciplinary Team (MDT). Consideration for clinical management and/or other team interventions is to be given during the course of the Daily Clinical Meeting.

Transfer of Clinical Management

Where transfer of care is required, particularly in the context of a long-term therapeutic relationship, the formal handover process should include discussion with the person, their identified supports (e.g. carers, family) and should outline current and past management strategies and any other relevant information that may impact on the new clinical management relationship.

Evaluation

Outcome Measures

Clinical managers will be allocated people managed by MHJHADS according to the procedures described above.

Method

Monitoring by Team Leaders/Managers of incident reports via Riskman and Consumer Feedback where appropriate clinical management allocation has not occurred or has not adequately met the standard as described in this Standard Operating Procedure.
Team Leaders will meet regularly (at least every 2 months) with each Clinical Manager to ensure oversight of their practice, review of their caseload and to offer support where required, as well as promoting quality assurance and improvement opportunities.
Clinical Case reviews should be conducted for each clinically managed consumer every 3 months (or ad hoc as required) to access MDT contributions to Recovery Planning.
Evaluation will also occur via a review of all aggregate Riskman incident data relating to clinical management allocation. This review will be conducted by the Operational Director of Adult Community & Older Persons Mental Health Services prior to the review date for this Standard Operating Procedure.

Related Legislation, Policies and Standards

Legislation

Mental Health(Treatment and Care) Act 1994

Health Records (Privacy and Access) Act 1997

Human Rights Act 2004

Policies

MHJHADS SOP: Clinical Handover in Community Mental Health Settings

MHJHADS SOP: Clinical Case Review in Mental Health Services

MHJHADS SOP: Confidentiality and Privacy

MHJHADS SOP:Daily Clinical Meetings in Community Mental Health Settings

MHJHADS SOP: Episode of Care Closure

MHJHADS Publication: Clinical Processes and Documentation Resource Package 4th edition.

Standards

National Standards for Mental Health Services 2010

References

King R, Lloyd C, Meehan T, Handbook of Psychosocial Rehabilitation. Blackwell Publishing 2007.

Shepherd G, Boardman J, Slade M, Making Recovery a Reality. Sainsbury Centre for Mental Health March 2008.

Auditor General’s Report No 8 of 2010: Delivery of Mental Health Services to Older Persons.

Attachments

Attachment 1: Mental Health Services recovery principles

Attachment 2: Principles of recovery-oriented mental health practice

Attachment 3: Mental Health Triage Scale

Attachment 4: Screening Guidelines for Mental Health Services

Disclaimer: This document has been developed by Health Directorate/ Mental Health, Justice Health, Alcohol & Drug Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Attachment 1: Mental Health services Recovery Principles

These principles have been developed to inform and guide the ACT community, and in particular mental health service providers, to support the spirit of recovery and enhance potential contributions to a person’s recovery journey. They have been developed after reflection on principles, dimensions and key elements from other states in Australia and around the world. Underlying these principles is acknowledgement of the unique nature of the recovery journey and the importance of creating a culture of optimism, healing and inclusion.

Hope is fundamental to a person’s recovery journey.

A person’s unique life context - encompassing, though not limited to, culture, spirituality, gender, age, life roles - is acknowledged and valued.

People are encouraged to take the lead in their recovery journey and collaborate with a range of services and supports as required.

Maintaining and developing connections to valued people and activities is critical to the recovery journey.

Partnerships are based on trust and mutual respect.

People are provided with the necessary information to enable them to make informed decisions about their recovery journey.

Everyone has responsibility for creating and sustaining a culture that promotes recovery

Attachment 2: Principles of recovery-oriented mental health practice

From the perspective of the individual with mental illness, recovery means gaining and retaining hope, understanding of one’s abilities and disabilities, engagement in an active life, personal autonomy, social identity, meaning and purpose in life, and a positive sense of self.

It is important to remember that recovery is not synonymous with cure.

Recovery refers to both internal conditions experienced by persons who describe themselves as being in recovery— hope, healing, empowerment and connection—and external conditions that facilitate recovery—implementation of human rights, a positive culture of healing, and recovery-oriented services1.

The purpose of principles of recovery oriented mental health practice is to ensure that mental health services are being delivered in a way that supports the recovery of mental health consumers.

1. Uniqueness of the individual