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CLIPP Index <
 CLIPP
(Consultation and Liaison in Primary Care Psychiatry) Manual
Needs Assessment
General Practitioners Needs Assessment
General Principles
Early involvement of the representative and organisational structures provided
by the Divisions of General Practice will be important to the success of
any such enterprise. Enthusiastic advocates within the GP community can present
role models to others, demonstrate the possibility of collaboration and promote
the wider adoption of the program. The consultation process prior to program
implementation will involve relating with several different organisations;
possibly several Divisions of General Practice, certainly a number of different
general practices. Each of these will have its particular culture. Adjoining
divisions may have very different processes of decision making and communication.
Practices vary greatly in size and organisation.
There is often an accumulation of frustration and sometimes anger that has
developed with time between GPs and mental health services. Characteristically
the GP resents the perceived unresponsiveness of the mental health service
to crises, and lack of communication with GPs when clients are referred to
mental health services. This picture may in many areas however have benefited
in recent years from educational and other initiatives that have promoted
face to face contact between GPs and AMHS providers. There is sometimes a
necessary period wherein GPs may need to feel their grievances have been
listened to and taken heed of. When necessary time for this has passed, more
positive collaboration may be established.
Key Points
- Establish links between GP divisions and mental health services early.
- Develop a mixture of formal and informal linkages.
- Cultivate enthusiastic and committed GPs to promote the program.
- Seek to provide equity of access to the program for all interested GPs.
- Within the needs assessment, present the CLIPP model as a possible direction
for development and determine which GPs would be interested in being involved
in such a program.
Specifics
Making Contact
- Establish initial contact with Director(s) of the Divisions of General
Practice, who have GPs in the catchment area boundaries of the AMHS.
- Clarify the geographical areas of responsibility and the extent of any
overlap between Division of General Practice and AMHS boundaries.
- Identify which Divisions are important collaborators with a particular
AMHS, also any special projects officers for mental health in Divisions.
- Gauge the interest, needs and resources of each Division of General Practice.
- Investigate the dynamics of Divisions of General Practice and the way
they manage their budget, programs and priorities.
- Review how the Divisions each develop the skills of their staff and manage
staff resources
- Research the demographics of the members of the Divisions and the commitment
to mental health by the Division and its members.
- Identify what have been successful projects for the Divisions in the
past and why these projects were successful.
- Discuss the best way and format of presenting project ideas to members
of the Divisions, in order to receive GPs' informal feedback.
If multiple Divisions are involved some discussion as to the possibility
of one taking an identified lead role in the process should be considered.
Establishing Continuing Relationships
Schedule a meeting to include all project workers from the AMHS and Divisions
to establish rapport, share information, outline the unique needs of each
organisation and outline the function of each organisation. The group should
establish clear communication processes, procedures, regular meeting times,
and a process for setting agenda items for discussion.
- The running agenda should include:
- What specialist skills exist amongst members of the group that can be
utilised for the project
- The knowledge of psychiatry possessed by the GPs in the Divisions
- The issues that affect sole practitioners versus group practices and
how they will be accommodated within the model.
- GP and AMHS training needs.
Ideally the working group should identify significant other people who could
be useful resources/support/advocates for the project. At this point the
establishment of a reference committee convened by the auspicing organisation
and including a wide range of stakeholders is desirable.
Assessing GP Needs
Collaboratively discuss, develop, implement and evaluate a GP needs assessment.
This can be done by employing a range of methods, including face to face
contact, meetings, written invitations and perhaps questionnaires. Gain feedback
regarding the needs assessment from a variety of sources, (if a reference
committee has been established this is an important place to access a broad
response). Use the needs assessment also to promote enthusiasm for collaborative
working. Within the needs assessment, present the CLIPP model as a possible
direction for development and determine which GPs would be interested in
being involved in such a program.
Area Mental Health Service Needs
Assessment
General Principles
Assessing the needs of AMHSs requires tact and care. General Practice liaison
is in many understandable ways a potential source of perceived threat for
AMHS staff. For instance, some staff may feel that liaison with GPs is something
they should have been doing as routine, so having a specific program set
up to do it can be seen as an imputation of professional failure. Also the
CLIPP protocols do involve a degree of peer scrutiny of clinical management
and this is often a threatening activity, however carried out.
The introduction of a substantial active process promoting transfer out
of the service can be felt to undermine long established relationships with
clients, and activate a very direct sense of personal loss for mental health
service staff. The idea that another provider in the community (the GP) may
be able in even a select number of cases to carry out the function of the
AMHS may be experienced as undermining.
Many AMHS staff will perceive that the GP setting is inappropriate for long
term management of people with mental health problems and will be concerned
that transfer may not be in their client's interests. This may be based in
prior adverse experiences of discharge to GP care, and is often an appropriate
and reasonable concern.
The process of educating the staff group about the model proceeds in tandem
with needs analysis, as does the collection of information and ideas that
may inform the particular implementation. It may be necessary to repeatedly
emphasise the case registration, tracking and quality assurance aspects of
the model so as to allay realistically based fears of loss of clients to
follow up. In implementations elsewhere the CLIPP model has been shown capable
of achieving very high levels of retention in continuous care.
Problems can emerge wherein the project team can be seen as privileged,
relatively insulated from funding constraints, and as having a focus on particularly
easy clients or on a range of problems that are not 'core business'.
Different individuals and services will illustrate such cultural attitudes
to different degrees and some may be almost entirely free of them. However
through the needs assessment process it will be important to provide opportunity
for such concerns to be listened to and not dismissed. The project implementation
team should make responses to them that are considered and careful if the
implementation process is to avoid the acting out of the conflicts these
ideas may generate in destructive ways.
It may be useful for the program development team to aim to provide useful
information on the mental health service to management and clinical staff.
This may include information on links between the service and GPs, information
on problems such as loss of clients to follow up, and suggestions about communication
protocols with GPs. Information and suggestions in these areas can, if presented
in a tactful and timely manner, helpfully be fed back to the leadership and
the AMHS teams.
Key Points
- Identify stakeholders, facilitate consultation and provide feedback.
- Anticipate resistance.
- Minimise extra work for staff.
- Try and offer value to the service and staff early.
- Emphasise commitment to continuity of care and quality assurance.
Specifics
Orientation
Orient to the AMHS, through formal and informal mechanisms. This includes
orientation to the evaluation and quality assurance structures in place,
AMHS technical processes including computer systems, technical tools, organisational
expertise, professional aptitude of project team and both formal and informal
controllers of power. Review established policies utilised by the AMHS for
consumers, carers, Psychiatric Disability and Support Services (PDSSs) and
GPs. Also consider standards of care including children of consumers, people
with preference for languages other than English and gender and discharge,
both from hospital and from the service. Review current Federal and State
health (physical & mental) policy documents, and applicable standards
for health care.
Gather Local Data
- Access any available statistics regarding general population demographics
and disease prevalences for the areas served by the AMHS.
- Access maps and ideally generate a wall mounted map which is to a uniform
scale and shows boundaries of the AMHS catchment, areas covered by local
divisions, and the location of mental health care facilities. As possible
sites of involved GPs become clearer such a map will help in the process
of prioritising the options for development and clarifying areas where
coverage is inadequate.
- Access any available AMHS statistics regarding its consumer population.
- Identify gaps in the information base that will be required for the program,
and consider strategies to close these gaps as part of the development
plan. If they are available include summary statistics of the following:
- Areas of residence of clients who attend the service.
- Language background of clients
- Usage of General Practitioners by clients.
Inform and Engage Staff
Conduct an AMHS staff development session. Include all project team members
in the planning and running of the session. As far as possible arrange for
the training to be carried out in normal hours and ensure that attendance
is given endorsement and accorded a high priority by management.
The aims of the staff development session is to inform staff of the project
brief, create consultative mechanisms for the project, and heighten their
awareness to the potential change that will result from the project.
An example of the possible content for a staff development session is as
follows:
- Elicit staff perceptions of their work with GPs.
- Outline the amount of work GPs potentially do with people with mental
health problems and mental health disorders, based on available mental
health prevalence statistics.
- Encourage information sharing associated with client discharge/shared
care and staff perceptions of what gets in the way of them transferring
clients to GPs.
- Highlight types of clients who are potentially appropriate for CLIPP.
- Background information about CLIPP; how it was established, how CLIPP
functions, what to expect from CLIPP and outcomes to date.
- Outline the role of the CLIPP liaison clinician.
- Open forum for feedback, discussion and questions.
Conduct small staff focus groups following staff education. Dependent on
the degree of engagement with the staff group in the program development,
and the nature of identified resistance these groups may be a helpful additional
strategy to enable all staff of the AMHS the opportunity to contribute and
participate in the evolution of the project from its onset.
Collate and Report
Summarise and report the information collated through these exercises. A
series of brief project reports presenting several of the above tasks as
brief documents, perhaps only a couple of pages at a time may be helpful.
The use of maps to present information can be important in matching the service
development to areas of need.
Consumer Needs Assessment
General Principles
Consumer participation is essential in ensuring the project's accountability,
promoting "best practice" in all aspects of the project work and gaining
consumers' participation in determining how their needs will be best met.
The consumer needs assessment should focus on service delivery positives
and negatives at the primary and secondary care interface. It should sample
attitudes about the type of service GPs do provide and should provide.
The type of needs assessment implementation strategy chosen should reflect
the purpose of the program and the roles that have been developed by, with,
and for consumers in the particular AMHS.
Key Points
- The consumer has a legitimate and important contribution to make to planning
and evaluation.
- Incorporation of consumer views should be commensurate with the general
culture of the service setting.
- Engaging effective consumer involvement should be more than inviting
an apparently willing consumer onto a committee. There are often needs
for support and development for the role of consumer representative. It
is easy to fall into the trap of tokenism and it is to facilitate full
participation by the consumers in the process.
Specifics
Work with Established Models if Possible
Identify whether the AMHS has a consumer participation structure. If there
is a service structure, clarify the process the AMHS utilises to engage in
collaborative partnerships with consumers. Use these processes where possible
to engage consumer participation in the development and monitoring processes
for this program.
If there is no service structure, take a role in facilitating a consumer
participation plan for the AMHS. Facilitate co-operative partnerships with
consumers, based on AMHS, State and Federal mental health policy. Identify
consumers interested in collaboration in the functions of the AMHS, more
particularly with an interest in primary care psychiatry, via the CLIPP liaison
clinician, client groups and advertising.
It is important to be realistic in the aims for the project and bear in
mind that effective consumer participation programs include support structures
for consumers in these roles, and take time and effort to develop. Simply
inviting an interested consumer onto a reference group or committee may be
tokenistic and ineffective as a strategy for proper consumer participation.
Develop a Consumer Involvement Strategy
Establish rapport with consumer representative(s) and outline the CLIPP
program brief. To facilitate this process evoke consumer response and invite
consumer involvement to elicit the best way to involve/include consumers
and to identify barriers to consumer participation. Develop a strategy for
consumer collaboration and consultation for the duration of the program,
taking into consideration the evolution phases of the process and the need
to be flexible. It is also important to identify the need for financial compensation
to reimburse consumers for their participation in CLIPP activities e.g. attendance
at meetings and negotiate such reimbursement if possible.
Use the Reference Group
Include consumer representation on any reference committee that may be established
in relation to the CLIPP program. Be open to the contribution of consumers
involved in the process. Consider that it may be healthy for consumer representatives
to take a leadership role in elements of the program and its evaluation.
Carer Needs Assessment
General Principles
The carers of those with serious mental illness in the AMHS often play critically
important roles in the care of the individual with disorder. Relationships
between the carer and the client may be strained because of consequences
of illness, but also because of normal family conflicts. Relationships between
carers and the mental health service may be complex with often multiple roles
occupied by the carer at different times in the course of the client's disorder.
Confidentiality can be a complex and challenging ethical issue. The transfer
to shared care can often generate understandable anxieties about rejection
by the AMHS, and fear for possible refusal of support if situations deteriorate.
Carers may have many real and understandable concerns and the opportunity
to involve them as participants in planning and communicate information about
the model will be important for success of any venture in this area. The
more experience we have with shared care in the CLIPP model the more important
effective engagement and communication with carers evidently becomes.
Specifics
Making Contact
- Initiate contact with existing regional carer group(s).
- Prepare an information brochure about the CLIPP model targeting carers.
- Meet with a carer representative and/or carer group.
- Use this meeting to outline the CLIPP model, hand out the prepared brochure,
receive feedback on their opinion of the model. Recruit an interested party
to sit on the CLIPP reference committee.
Develop a Carer Involvement Strategy
It is important to consult carers and elicit the best way of informing and
including carers in the process of the evolution and implementation of the
project, so that their opinions are heard and acknowledged. Develop a strategy
of action/information that will best meet the needs of carers and the AMHS
and establish an open dialogue between both parties. Information provision
is vital throughout this process so produce regular newsletters to send to
the carer group/ carers and maintain a regular spot on the carer group's
meeting agenda to pass on information.
Psychiatric Disability Support Services Needs Assessment
General Principles
Many of the clients suitable for transfer into shared care may also have
relationships with Psychiatric Disability Support Service (PDSS) providers.
They may be residents of long-term care facilities, attenders at day care,
or residents of supported accommodation of various types. Many PDSSs have
linkages with local GPs and it will be important to arrange any new shared
care initiatives so that they acknowledge and do not disrupt such arrangements.
The arrangements should instead complement them and offer helpful adjunctive
input.
Specifics
Brief PDSS Manager
Contact PDSSs allied to the AMHS and arrange a time to meet and discuss
the program with the PDSS Manager. The program brief can be a useful document
in this instance in that it may provide accessible information for the PDSSs.
Assess initial reaction of the PDSSs, encourage them to disperse information
about the program to staff and consumers and gather further feedback
Invite representation from a variety of PDSSs to participate in the project's
reference committee and place interested PDSSs on a mailing list to receive
regular updates and information pertaining to the project. |
