CLIPP Index <

CLIPP (Consultation and Liaison in Primary Care Psychiatry) Manual

Introduction

• The CLIPP Model
• Background
• References

The CLIPP Model

The CLIPP model has three elements which in synthesis can enable effective collaboration between Private and Public sectors.

1. A well-defined consultation, liaison and educational model involves co-location of mental health service medical staff in the General Practice setting. This facilitates early intervention by GPs with input from a specialist for people whose disorder presents in primary care. It does this in a format that empowers the GP as clinical manager and educates him or her around a focus generated by the care needs of the presenting individual.

2. A rigorous process, performed by a nurse clinician with this task as a core duty, selects and prepares appropriate clients from the AMHS for transfer to GP care. This clinician then coordinates preparation of documentation and the smooth implementation of the transfer.

3. A case register maintained by an administrative staff member in the mental health service supports monitoring procedures targeted at ensuring high levels of retention in effective follow up for clients in shared care.

Central to the success of the model has been:

• A high degree of personal contact between GPs and the mental health service staff, permitting the development of sound and informed professional working relationships.
• The development of a shared commitment to provision of mental health care to people troubled by the entire range of disorders, and an acknowledgment of the capacities of both mental health service staff and GPs to take positive roles in care across this whole range.

The materials in this manual will explain much of the process of the development of the CLIPP model and its day to day running. The layout is intended to guide the particular reader to the most useful parts of the document quickly.

Background

The Challenge of Primary Care Psychiatry

The Australian Bureau of Statistics has reported during 1998 the most extensive study of mental health problems ever carried out in this part of the world ¹. The report provides evidence of the significance of the role GPs play in delivery of care for mental health problems. Some relevant findings follow:

• In 12 months prior to interview, 17.7 per cent of the Australian population had experienced a mental disorder.
• 9.7 per cent of the population had experienced anxiety disorders, 5.8 per cent affective disorders, and 7.7 per cent substance use disorders.
• 38.0 per cent of those with mental disorder, and a total of 11.1 per cent of the Australian population, made use of any health services for their mental health problems.
• Among people with active mental disorders in the last year, service use for a mental health problem by type of provider showed the following pattern.

This finding of the General Practitioner as being substantially the most frequent provider of services to individuals with mental health problems is robust across mild, moderate and severe levels of disability. The survey, through the above findings, shows how important the GP is as a provider of care to the majority of people with mental disorder. The survey was designed best to enumerate high prevalence disorders such as anxiety, depression and substance misuse, however in addition to this role with high prevalence disorders, GP also have a significant role with management of less common disorders including schizophrenia. A recent survey has found 31.2 per cent of people with schizophrenia receiving mental health services input solely from GPs ².

The quality of care provided by GPs to people with schizophrenia and similar mental health problems has received little systematic audit in Australia. However there is reason to believe from international work ³, ⁴ and some suggestions from work in Australia ⁵ that it may tend to fall below desirable standards.

Promoting Collaboration at the Primary/ Secondary Interface

Standards of care in General Practice might be improved by the provision of specialist support to GPs. This could be provided from the private sector with its funding provided through Medicare. However, the incentives in the Medicare system, it has been argued, are not optimised to promote equitable and ideally cost effective utilisation of the resource of specialist psychiatrist in mental health care ⁶, ⁷, ⁸. There are various examples of evidence of inequality of access to private specialist mental health care ⁵, ⁹, ¹⁰, ¹¹, ¹² and provision of specialist services to rural areas is a concern ¹³.

State funded services, an alternative possible source of support for GPs, operate with rigid expenditure limitations.¹⁴ Under the first National Mental Health Plan they have had a declared focus towards serious mental illness, primarily psychotic disorders or other disorders with high levels of associated disability. ¹³, ¹⁵ Often the provision of care by these services is not coordinated with care delivery provided by the GP, and GPs have often reported difficulty accessing support from the public sector.

There is a risk that some individuals with significant needs for mental health care may fall through cracks in this somewhat disjointed system. Also, there may be little space in this service structure for preventative or early intervention work.

Against this background Commonwealth policy has promoted development of novel models for collaboration between sections of the mental health care system. ⁶, ⁷, ¹³, ¹⁶, ¹⁷, ¹⁸ The Second National Mental Health Plan emphasises effort towards such partnerships. ¹⁹ Also the Second Plan emphasises a broadening of the focus of disorders for attention by mental health services, including the assumption of an active role in the management of depression.

The model presented here is an example, among other things, of the positive outcomes of effort and involvement from Government at various levels. Priming monies from the Commonwealth Department of Health and Family services supported development of the model. State Government agencies have also been consistently supportive ²⁰, and the emergence of the model here set out has made some contribution to forming state policies on practice in this area. ²¹, ²² The history of this service development also includes the winning of a National Mental Health Achievement Award in 1996 ²³, these awards being supported by the Commonwealth Government. Finally the production of this set of materials has been supported by a grant from Human Services Victoria.

Adaptation of these Protocols for Use in Other Settings

The materials in the manual include examples of procedures and documentation that have been successfully developed in one setting, then adopted for use in some other services that have taken on the model. For those developing their own services, flexibility in application of the model should be emphasised while retaining emphasis on fundamentals such as collaboration, communication, quality assurance and continuity of care.

Caution

Even the best designed forms and protocols do not themselves make for sound clinical process. This requires also appropriately committed, supported, skilled and supervised staff. It also requires skillful negotiation and communication between groups of service providers who may previously have had little contact. All of this needs to be led and maintained with clear and positive leadership and the tangible commitment of resources to the task.

For details of CLIPP forms, please see Appendix 2.

Contact Details

Requests for licenses to make use of the materials or for further information on the model can be directed to

Graham Meadows
Professor of Adult Psychiatry, Monash University,
Dandenong Hospital,
PO Box 956,
Victoria 3175
Australia.
email: Graham.Meadows@med.monash.edu.au
Phone +61-(0)-3-9554-1585

References

1. Australian Bureau of Statistics, Mental Health and Wellbeing: Profile of Adults, Australia 1997, 1998, Australian Bureau of Statistics,: Canberra.
   
   

2. Lewin, T.J. and V.J. Carr, 'Rates of treatment of schizophrenia by general practitioners: A pilot study', Medical Journal of Australia, 1998. 168(4): p. 166-169.
   
   

3. Nazareth, I.D. and M.B. King, 'Controlled evaluation of management of schizophrenia in one general practice: A pilot study', Family Practice, 1992. 9: p. 171-172.
   
   

4. Nazareth, I.D. and M.B. King, 'Schizophrenia: community care and the family physician', International Review of Psychiatry, 1992. 4(3-4): p. 267-271.
   
   

5. Meadows, G. Joubert L. Harvey, C. Mcrone P 'Consultation, Collaboration and Cost Effectiveness: Reflections on Four Years of Shared Care in Melbourne' in 'Shared Care" - Proceedings of the 1997 Geigy Psychiatric Symposium, 1999. Novartis, Sydney: p. 41-56.
   
   

6. McKay, B., Proposals for change Final report: Optimum supply and effective use of psychiatrists, 1996, Bernie McKay and Associates.
   
   

7. McKay, B., Issues and Options Supplementary paper: Optimum supply and effective use of psychiatrists, 1996, Bernie McKay and Associates.
   
   

8. Solomon, S.A., B.A. Buckingham, and M. Epstein, Report of Consultancy for the Mental Health Workforce Committee on Medical Workforce Financing Arrangements, 1993.
   
   

9. Jorm, A.F. and A.S. Henderson, 'Use of private psychiatric services in Australia: An analysis of Medicare data', Australian and New Zealand Journal of Psychiatry, 1989. 23(4): p. 461-468.
   
   

10. Jorm, A.F., S.J. Rosenman, and P.A. Jacomb, 'Inequalities in the regional distribution of private psychiatric services provided under Medicare', Australian and New Zealand Journal of Psychiatry, 1993. 27: p. 630-637.
    
    

11. James, N., Personal Communication, 1997.
    
    

12. Meadows, G., 'Geographical resource allocation for public mental health services in Victoria', Australian and New Zealand Journal of Psychiatry, 1997. 31: p. 95 - 104.
    
    

13. Australian Health Ministers, National Mental Health Plan, Mental Health Branch, Commonwealth Department of Health and Family Services. Canberra 1992.
    
    

14. Department of Human Services Victoria, Purchasing Better Mental Health Services in Victoria, 1996, Department of Human Services Victoria Psychiatric Services Division.
    
    

15. Department of Health and Community Services Victoria, Victoria's Mental Health Services: The Framework for Service Delivery, 1994, Department of Health and Community Services, Psychiatric Services Division, Melbourne.
    
    

16. Australian Health Ministers Advisory Council, Better Health Outcomes for Australians, 1994, Canberra: Commonwealth Government Publishing Service.
    
    

17. Centre for General Practice Integration Studies, GP Integration Projects, 1997, University of New South Wales: Sydney.
    
    

18. Department of Evidence-Based Care and General Practice. 'The General Practice Evaluation Program'. in The 1997 General Practice Evaluation Program Conference Proceedings. 1997. South Australia: Flinders Press.
    
    

19. Australian Health Ministers, Second National Mental Health Plan, 1998, Mental Health Branch, Commonwealth Department of Health and Family Services, Canberra.
    
    

20. Meadows, G., 'Establishing a collaborative service model for primary mental health care', The Medical Journal of Australia, 1998. 168(4): p. 162-165.
    
    

21. Department of Health and Community Services Victoria., General Practitioners and Mental Health Services: Shared Care Projects: Interim Report, 1995, Melbourne: Health and Community Services Victoria.
    
    

22. Department of Human Services Victoria., Sharing the Care: General Practitioners and Public Mental Health Services. 1996, Melbourne: Human Services Victoria.
    
    

23. Meadows, G. and L. Joubert, 'Silver Award- Category- Prevention or health promotion service or project', in There's a Person in Here, proceedings of the 1996 Mental Health Services Conference of Australia and New Zealand. M. Teesson, et al., Editors. 1996, Ian Liddell Pty. Ltd.: Brisbane.

    
    

24. Meadows, G., et al., 'The pattern of care model: A tool for planning community mental health services', Psychiatric Services, 1997. 48(2): p. 218 - 223.