3. Practice

Public mental health services are configured in three main service settings:

• acute inpatient
• ambulatory
• community residential.

The process of assessment, review, referral and discharge and the subsequent documentation of these processes are critical in providing a safe quality mental health service. In the unfortunate situation of adverse events or critical incidents, the quality of the care and the quality of the documentation is often called into question.

The recording of consumer outcomes follows an assessment by the clinician. Therefore the clinician ratings should confirm or correspond to the information contained in the consumer’s clinical file. There should be an entry in the clinical file to indicate if a consumer self-assessment has been offered and the result of that offering. Consumer outcomes information should be considered in all aspects of clinical practice and utilised, where appropriate.

If the clinician rated consumer outcomes are completed following an assessment and are making overt a clinician’s assessment, then it is important to explore the occurrence of missing items. Missing items might occur because an item has been skipped or because the rater has opted for a rating of 7, 8 or 9 (unable to rate) on the clinician rated measures. Consider:

• What might it mean if, following an assessment, there are areas that are unknown or unable to be rated?
• What does it mean if there are subsequent 7, 8 or 9 on later collection occasions?

3.1 Assessment

“Standard 11.3 – ASSESSMENT AND REVIEW, Consumers and their carers receive a comprehensive, timely and accurate assessment and a regular review of progress. Specifically:

• 11.3.5 The assessment process is comprehensive and, with the consumer’s informed consent, includes the consumer’s carers (including children), other service providers and other people nominated by the consumer.
• 11.3.6 The assessment is conducted using accepted methods and tools.”

(Australian Health Ministers Advisory Council (AMHAC) - National Mental Health Working Group, Information Strategy Committee, National Standards for Mental Health Services, December 1996)

“Standard 7: ASSESSMENT, TREATM ENT, RELAPSE PREVENTION

AND SUPPORT Mental health professionals provide or ensure that consumers have access to a high standard of evidenced based assessment, treatment, rehabilitation and support services which prevent relapse and promote recovery. They monitor the appropriateness and effectiveness of interventions.” (Australian Health Ministers Advisory Council (AMHAC) - National Mental Health Working Group, Information Strategy Committee, National Practice Standards for the Mental Health Workforce, September 2002).

Assessment is a key function of mental health service delivery.

Assessments and case formulations are routinely completed for consumers of public mental health services, they may be comprehensive or as a routine monitoring function. A range of complex information is available from multiple perspectives, and consumer outcomes present one way of making the information on the consumer journey readily accessible.

Assessments should be informed by all available information on a consumer including collateral information from key informants such as case manager and family members, history documented in both the inpatient and community files, and information available on the electronic databases. A review of the consumer’s inpatient file and access to community file is time intensive and limited by access and availability to medical records.

Documentation is essential for good mental health care and yet, there is considerable variability in the quality of assessments undertaken and their documentation. The clinician rated consumer outcomes provide a standardised process for making overt the clinicians’ judgement following an assessment. Consumer outcomes provide a common language for clinicians, consumers, teams, organisations and also for jurisdictions.

Assessments can occur for:

• new consumers who have never accessed public mental health services
• new consumers to a service who have been seen in another service
• existing consumers transferring to another program in your service
• existing consumers who have been treated in another setting (for example an ambulatory consumer who has been admitted and discharged from an acute inpatient unit and now returning to ambulatory care)
• known consumers who have been previously discharged.

Assessments require:

• obtaining information from key informants
• reviewing all available information
• assessment of the consumer.

Assessments will inform decisions regarding most appropriate actions such as:

• referral to external agency - no further assessment or specialist intervention required
• conducting a further assessment with possibility of brief interventions
• admission in an acute psychiatric inpatient unit, a community residential unit or into a community mental health service.

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How might consumer outcomes be used at entry into ambulatory setting following an assessment?

For new consumer:

• Are there group programs that could be accessed?
• Has referral to additional/external supports been undertaken?
• Has this consumer accessed a mental health program/initiative delivered through general practice? If so, are consumer outcomes available from this?
• How consumer outcomes inform the plan for immediate management of the consumer (i.e. why you managed the client as you did following assessment)?
• For intake/assessment teams, the ratings may help the decision regarding management of the consumer through a general practice program such as Mental Health Nurse Incentive Program or Better Access to Mental Health Care Initiative or another program in the community (referral plan).

For existing consumers:

• Is this consumer returning to ambulatory care following an admission and discharge from an acute inpatient unit? If so how does their presentation now compare with the presentation on previous returns to an ambulatory setting?
• Is the consumer prepared to complete a consumer self-assessment? Is this consistent with previous collections? What have they identified as issues?
• Would this consumer benefit from more intensive treatment?
• Would referral to community residential program (where they exist) be appropriate?
• Are there group programs that could be accessed?
• Has referral to additional/external supports been undertaken?
• The consumer outcomes might inform the needs assessment (which will inform the Care Plan).

How might consumer outcomes be used at admission to inpatient unit following an assessment?

Consider the following:

• Has this consumer been admitted before? If so how does this presentation compare to the previous admissions? Are individual items, subscale or totals similar or different?
• Is this consumer an existing consumer of the mental health service? If so, what is their usual level of functioning and symptom severity? Have they previously completed a self-assessment measure? If so, what did they identify as issues?
• Is this consumer’s admission assessment consistent with “like” consumers? That is, how does this consumer’s HoNOS/HoNOSCA/HoNOS65+ compare with other consumers on admission to an inpatient unit?
• For both new and existing consumers:
  • What do the measures suggest regarding the goals of the admission and the treatment needs/strategies during the admission (for instance, that might be targeted by psychosocial strategies, e.g., sleep, anxiety management, referrals to accommodation agencies etc)?

For new consumers:

• Would this consumer benefit from referral to ambulatory services (though this may be easier to determine on review in the inpatient setting)?
• Are there group programs that could be accessed?
• Has referral to additional/external supports been undertaken?
• Has this consumer accessed better mental health program or access to mental health nurse practitioners? If so, are consumer outcomes available from this?

For existing consumers:

• Is the level of community care sufficient?
• Would this consumer benefit from a more intensive level of support?
• Would referral to community residential program (where they exist) be appropriate?
• Are there group programs that could be accessed?
• Has referral to additional/external supports been undertaken?

Refer to: 3.3 Review

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3.2 Care plans

“10.6 Each consumer has an individual care plan within their individual clinical record which documents the consumer’s relevant history, assessment, investigations, diagnosis, treatment and support services required, other service providers, progress, follow-up details and outcomes” (Australian Health Ministers Advisory Council (AMHAC) - National Mental Health Working Group, Information Strategy Committee, National Standards for Mental Health Services, December 1996).

It is important to follow relevant local or jurisdiction documentation suites and care plan templates.

Care plans are another opportunity for consumers and carers (where appropriate) and clinicians to articulate goals and planned interventions. They should be developed in collaboration with consumers and carers and are particularly important where there are multiple clinicians or agencies involved as it provides a space to clarify respective roles and perspectives.

The completion of the clinician rated consumer outcomes are summaries of this assessment, making overt the clinicians judgement. Care plans are informed by assessments and dialogue between the consumer, clinician, carer and other relevant service. Consumer outcomes are a part of the assessment process.

In order to ensure the consumer perspective is included in the development or review of the care plan, it is important to provide sufficient notice and time for offering and completion of the self-assessment measure.

Generally speaking, there is considerable variation in care plans between consumers, clinicians, teams, services and jurisdictions. While responding to variability in consumer needs is important, the variation often occurs in relation to:

• the value and expectation of the plan
• quality of information included
• degree of collaboration with consumers in the completion and review
• frequency with which they are reviewed
• process for which they are developed, with some services requiring the plan to be:
  • written with the consumer in the consumers language
  • developed by the clinician with input after development by the consumer
  • signed by the consumer with some requiring indication of whether the consumer (a) agrees, (b) were involved in its development and/or review or (c) just provided a clinician developed copy.
• process for which they are reviewed with some services requiring the plan to be reviewed by the:
  • clinician
  • treating doctor
  • multidisciplinary team.
• inclusion and reference to other activities such as risk assessment and consumer outcomes.

Examples

Consumer identified areas

The consumer outcomes can also identify areas of strength for the consumer and it is important that these are also acknowledged. These areas of strength can then be drawn on when working towards goals.

While there is significant variation in the type of information in care plans (however named), ideally they should be largely informed by consumer-identified needs. For some consumers who are not actively involved in their treatment, or who are unwell, this may not be possible.

This information could be informed by:

• consumer self-assessment ratings
• clinician ratings of consumer outcomes
• dialogue between the consumer and clinician.

It is unrealistic to expect that consumers and clinicians will have the same perspective.

By virtue of their experience, knowledge, training and values they will have different explanations on attribution, expectations and outcomes as well as having different priorities and goals. Consumer outcomes are a unique opportunity for the consumer to rate how they think they are going. This process complements and enriches the clinician’s assessments and ratings.

Disagreement can be healthy and can form the basis for exploring differences in perspectives thereby providing opportunities for a genuine and effective therapeutic relationship.

Inclusion of clinically significant items

(Rating of 2 or more on the HoNOS/HoNOSCA/HoNOS65+)

The basic rule of thumb is that a rating of 2 or more on the HoNOS/HoNOSCA/HoNOS65+ is clinically significant and should at least be monitored. It is recommended that a rating of 2 or more should be included in the consumer’s treatment and management plan.

Discussion of clinically significant items is one way to prioritise areas for consumer and clinicians for future interventions. This is a guide only and sometimes issues that are rated 0 or 1 might be included in a treatment plan and should be negotiated with the consumer and carer.

Inclusion of carer perspective

A process for negotiating the focus of the care plan and respectfully valuing all perspectives is vital. The capacity to elicit the carer’s perspective and to facilitate inclusion of this into the care plan will be dependent on the relationship between the clinician/consumer, clinician/carer (or parent), and the consumer/carer.

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Child and adolescent/youth mental health services

The parent version of the Strengths and Difficulties Questionnaire (SDQ) makes it relatively easy to integrate carer perspectives. Inclusion in the care plan might consider:

• Areas of agreement and disagreement between youth and parent ratings.
• Areas of similarity or difference between the young person, parent and clinician between the self-rated and clinician rated measures.

Adult and older person mental health services

The absence of a carer measure in the consumer outcomes suite for adult and older person mental health services makes the routine inclusion of carers’ perspectives more difficult.

This process might be complicated by consumer consent issues for the active participation of carers in treatment and planning. Depending on the therapeutic alliance between clinician and consumer and clinician and carer, it is possible to consider the following for inclusion in the care plan:

• What is the carer’s perspective on the clinician and consumer ratings? Are the identified areas of difficulty consistent with the carer’s perspective?
• What is the carer’s contribution to assisting the consumer manage their difficulties? If the carer support was not provided, would there be other areas of difficulty identified?
• What does the carer identify as priority areas? What role might they play in assisting the consumer to manage those areas?

3.3 Review

“11.3.14 The MHS ensures that the assessment is continually reviewed throughout the consumer’s contact with the service” (Australian Health Ministers Advisory Council (AMHAC) - National Mental Health Working Group, Information Strategy Committee, National Standards for Mental Health Services, December 1996).

Consumers accessing public mental health services present with complex needs and routine review of both the consumer’s presentation and the clinician’s interventions is critical to ensure concerted effort towards an end goal of enhanced quality of life for the consumer and their family.

In addition to the mandated requirements for review, such as mental health review boards/tribunals and multidisciplinary clinical reviews, a review might be undertaken when a consumer transfers to another team/program in your service, or because a consumer has requested a review.

Review of multiple consumer outcome collections can be a helpful way of tracking change for consumers who find it difficult to:

• Prioritise areas to focus on
• Identify change and improvement using the consumer outcomes to explore:
  • What has changed and why?
  • What has not changed?
  • What interventions have been tried for clinically significant issues?
  • What interventions might be tried?
  • What other circumstances in the consumer’s life are contributing the measures increasing/ decreasing/staying the same?

The clinician rated consumer outcomes are completed following an assessment by the clinician and the ratings should support clinical judgement. These ratings may negate areas of concern or justify a particular treatment decision.

A risk assessment or review should be informed by all available information including observation, information from key informants and previous histories/documentation and should also include the consumer’s perspective. The consumer self-assessment measure is one way of obtaining the consumers perspective.

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Examples of reviews

Consumer outcomes could be used in one of the following types of review:

• Multidisciplinary
  • clinical review
  • transfers
• statutory body
  • mental health review board/tribunal
  • Office of Chief Psychiatrist
• additional supports/external agencies
• group program
• clinical supervision
• review requested by the consumer.

Multidisciplinary review

Most consumers of public mental health services have complex needs and benefit from a multidisciplinary review of their presentation as well as an exploration of multi-faceted treatment and interventions. This type of review is usually undertaken through the clinical review processes. In addition to the routine multidisciplinary clinical review, on occasions consumers may be referred for discipline-specific assessment and treatment, for example to an occupational therapist for skills in daily living or a social worker for family therapy.

The consumer outcomes can provide an overview of clinician and consumer perceived difficulties over time. The longitudinal capacity of the consumer outcomes can provide the evidence and can inform the referral request.

Clinical review

“11.3.17 All active consumers, whether voluntary or involuntary, are reviewed at least every three months. The review should be multidisciplinary, conducted with peers and more experienced colleagues and recorded in the individual clinical record” (Australian Health Ministers Advisory Council (AMHAC) - National Mental Health Working Group, Information Strategy Committee, National Standards for Mental Health Services, December 1996).

Most consumers of public mental health services have complex needs and benefit from a multidisciplinary review of their presentation as well as an exploration of multi-faceted treatment and interventions. This type of review is usually undertaken through the clinical review processes.

Clinical review or ward round processes vary considerably across services. Incorporation of the consumer outcomes provides a structure for dialogue about the consumer’s presentation and the clinician’s interventions. Incorporation into the clinical review will require preparation by the presenting clinician. Some teams will use data projectors and laptops during the review to either complete measures live, to generate the graphs live while some other teams will print out the graphs and present these to the meetings. Both of these technologies can enhance the process; however use of consumer outcomes can occur successfully without either of these approaches when preparation is undertaken.

The National Outcomes and Casemix Collection (NOCC) Protocol provide a minimum requirement for collection. Scheduled clinical reviews may not be aligned with the NOCC

91-day collection requirement for consumer outcomes, this may be because a consumer has had an admission or discharge into an inpatient unit, or a discretionary review may have been completed. If this is the case there are two options to tie in the consumer outcomes with a scheduled clinical review, with number one being the recommended option:

1. Complete a discretionary review (also known as ad hoc review, review other) to tie in with the upcoming clinical review. If the consumer outcomes are going to be presented at the clinical review it is really important to offer the consumer self-assessment measure with sufficient time to allow a completed copy to be returned prior to a scheduled clinical review to ensure that all relevant measures are available for the review meeting. Also there needs to be sufficient time for the completed measures to be discussed with the consumer.
2. Use all existing collections in the review and collect at the next scheduled 91-day requirement. There could potentially be some issues with using the ratings in this way because it may mean that the relevance/currency of the ratings is limited. That is, a person’s presentation today might be markedly different from the ratings completed some weeks previously.

Examples for clinical reviews

Exploration of consumer perspective

Consumer participation in self-assessment can highlight issues related to therapeutic alliance, engagement in treatment/therapy, acceptance of illness as well as differentiating priorities in treatment goals between the consumer and clinician. Consider the following:

• What was the reaction of the consumer to completing a self-assessment measure?
• What was the extent of participation - discussion, partially completed or fully completed? Has this participation changed? For example, have they previously participated and now refusing or have they previously refused and now participating.
• What were the ratings and how do they relate to your perception of difficulty/distress?
• How did they respond to feedback on the consumer measure?
• How did they respond to feedback on the clinician measure?
• What is the consumers understanding of the clinical review process and how their consumer outcomes inform this?

For more information on offering the consumer self-assessment including considerations like literacy, cultural status and ways to promote completion:

Refer to: 2.2.1 Offering

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Rate as a group

This activity is perhaps most useful in teams where there are more than one clinician involved in the consumers care. Rating as a group is an opportunity to share perspectives, developing an understanding and confidence of the measures and engaging collaborative information exchange, development of the use of a consistent terminology and language. Subsequently this technique can improve inter-rater reliability.

Rating as a group can be done:

• Prior to the clinical review enabling the team to work through points of difference considering all perspectives and sources of information. This enables discussion in the round or review to focus on actions and interventions.
• As part of the clinical review for consumers where there is significant difference of opinion and is a helpful way of gaining agreement for interventions.

Exploration of clinically significant items (rating of 2 or more on the HoNOS)

(Version modified by QUATRO VIC for staff training)

The basic rule of thumb is that a rating of 2 or more on the HoNOS/HoNOSCA/HoNOS65+ is clinically significant and should at least be monitored. It is recommended that a rating of 2 or more should be included in the consumer’s treatment and management plan. Discussion of clinically significant items is one way to prioritise areas for consumer and clinicians for future interventions. This is a guide only and sometimes issues that are rated 0 or 1 might be included in a treatment plan and should be negotiated with the consumer and carer.

There are other activities underway nationally to provide advice on what a junior clinician might do with a particular rating on the HoNOS suites.

Exploration of one measure at one point in time

Review of one measure at one point in time is limited, especially for the clinician measures as the clinician may not glean anything new if they have completed the rating. However, it does help to justify the management plan and perhaps any new goals established in the review as well as possibly being helpful to members of the clinical team not directly involved in the assessment. The consumer self-assessment measure can provide new information and a different perspective and can indicate areas of agreement and disagreement between the consumer and clinician. This process may alter team members’ perspectives.

For a new consumer, there will only be one collection occasion in which to review. Comparison of this individual collection with the clinical reference material may be beneficial. Is the rating for the consumer consistent with other similar consumers’ ratings? If not, are the ratings higher or lower and what might that mean for the proposed period of care.

Exploration of difference between consumer and clinician measures

It is unrealistic to expect that consumers and clinicians will have the same perspective. By virtue of their experience, knowledge, training and values they will have different explanations on attribution, expectations and outcomes as well as having different priorities and goals.

Consumer outcomes are a unique opportunity for the consumer to rate how they think they are going. This process complements and enriches the clinician’s assessments and ratings.

Disagreement can be healthy and can form the basis for exploring differences in perspectives thereby providing opportunities for a genuine and effective therapeutic relationship.

For example a consumer who is on a community treatment order receiving mandated treatment who rates themselves as having absolutely no problems might be at risk of deteriorating if the order is removed and people become non-compliant with treatment, they may deteriorate, and risk relapse. Equally a consumer, who rates significant areas of distress but who the clinician rates low, might be at risk of re-presenting if being considered for discharge.

Exploration of ratings for consumers who are stable/unchanged

It is often easier to identify consumers who are obviously getting better or worse and to make recommendations on treatment interventions. However, the ability to identify small or incremental change is difficult without measurement tools. The routine use of measurement tools will not only allow identification of small or transient change they also identify those consumers who remain stable. A consumer who remains unchanged across multiple time points may warrant consideration of different treatment or therapies. If we anticipate that there is further improvement or gains to be made then we may be unlikely to continue with the same approach. Consumer outcomes may also provide a baseline for determining where the consumer has come from and how sustained has previous improvement been.

For this group of consumers, prioritise one or two clinically significant items that have remained stable where focused energy, treatment and interventions will be undertaken and where you would expect a change by the next review.

Again check the clinical reference material. Are there similar consumers who remain stable/unchanged?

Exploration of ratings for consumers considered for transfer or discharge

In addition to other clinical data/information the consumer outcomes provide longitudinal evidence of deterioration, lack of change or improvement which can be used to advocate for referral or acceptance into or out of specific programs. Transfer could occur to (a) replace the team/clinician currently engaged with the consumer or to (b) complement the therapies already provided.

Consider whether this consumer would benefit from referral and transfer to a:

• less intensive service (from crisis/mobile support to case management/continuing care)
• more intensive service (from case management/continuing care to mobile/crisis support)
• discipline specific therapist
• community residential service
• therapeutic or educational group program run by the mental health service
• external agency.

Consumer outcomes can support the decision to transfer or closure.

Consider whether this consumer is suitable for discharge from the mental health service.

For some consumers there is anxiety in being discharged from a mental health service to community supports and general practitioner. The consumer outcomes can longitudinally represent change and improvement and consequently allay the consumer’s fears. As part of the discharge process and plan, it is useful for consumers and their families to include areas of previous difficulty and the strategies/treatment to manage or alleviate these areas.

Exploration of consumers over multiple collection occasions

File reviews are time intensive and limited by the quality of the information recorded.

Perhaps the greatest benefit of consumer outcomes is the standardised format and routine requirement which allows easy comparison of assessments over time.

Comparison of one measure across multiple time points identifies areas of improvement or deterioration and provides evidence for continuing with a current treatment or therapy, or application of alternative or additional supports. It is possible to review measures by individual item, subscale or total score.

In reviewing the clinician rated measure over multiple time points:

• Is the number of clinically significant items increasing, stable or decreasing?
• Are the clinically significant items stable or different between collections?
• Are there changes/differences in the ratings consistent with areas of intervention and/ or knowledge of other changes in the consumer’s circumstances (change may not be intervention related) and your expectations of change?

In reviewing the consumer rated measure over multiple time points, what does it mean if:

• Consumer has gone from refusal, to partially completing to fully completing? Or vice versa.
• Consumer rates the exact same way every time? For example rating all zeros.
• Consumer has been able to identify their areas of strength and difficulty that are increasingly consistent with others perspectives?

The consumer outcomes provide an opportunity to analyse factors and consumer profiles related to readmission and relapse. This can be done in one of three ways, ratings on admission, ratings on discharge or variation in ratings between admission and discharge.

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Comparison of admission ratings

• Are the scores (total, subscale or item) similar on each admission, are they lower or higher?
• Is there a change in the types of issues/difficulties?

Comparison of discharge ratings

• Are the scores (total, subscale or item) similar on each discharge, are they lower or higher?
• Is there a change in the types of issues/difficulties?

Comparison between previous admissions and discharges – clinician rated measures

Is there:

• No change? It is rare for consumers to be admitted and discharged on the same score over multiple admissions.
• Increase? It appears that the consumer’s level of functioning and symptom severity is improving with each admission. That is in addition to the general/expected reduction from admission to discharge the change is greater for example total score ratings on admission and discharge (16-12, 16-10, 18-8).
• Stable? That is there is a consistent level of reduction in total score regardless of actual score. For example a consistent reduction of 5 (20-15, 18-13, 19-14, 16-11).
• Decrease? It appears that the consumer’s level of functioning and symptom severity is worsening and that while there continues to be an ’artificial’ change from admission to discharge the actual level of improvement on each admission is getting less. For example (20-15, 20-16, 21-16, 20-18).
• Identification of what needs to be addressed in subsequent care plans to address the pattern of relapse if a similar precipitant is identified for each admission (e.g., substance misuse, communication skills)?

Ratings over multiple time points (including the difference in perspective) can be used in case conferencing, referral to practitioner or other appropriate services (non-tertiary service) to convince consumer to have involvement of external agency.

Using HoNOS to help plan for care and recovery

This framework was developed by Malcolm Stewart in New Zealand and can be used with any type of service that rates any of the HoNOS family of measures, whether they are child and adolescent services, working-age adults, or older adults. The tool proposes ways the HoNOS suite of measures can be used in planning care and recovery and is broken into three sections:

• Are we the right service?
• Check out the Three Cs – Concordance, Change, Concerns
• Choose the Top Priority.

There are a range of resources to support this process including both a ‘video’ and PowerPoint presentation about using this strategy, the ‘Quick-Guide’ posters that are given to individual trainees and put up on meeting room walls, and an ‘MDT Form’ to help people to think through a case and present it to their teams. These are all available free of charge and can be accessed via the internet. There is potential for this model to be adapted to include all the NOCC measures used in Australia.

For more information visit: www.tepou.co.nz/page/420-Information-Utility

Comparison with clinical reference material (e.g. AMHOCN DST)

The clinical reference material provides an opportunity for clinicians, consumers and families to confirm if the consumer’s presentation is consistent with other similar consumers. That is, normative data compares an individual to the community in general whereas the consumer outcomes clinical reference material available on the AMHOCN web-based decision support tool compares a consumer with the population under public mental health care. This can be a normalising process for consumers and carers and can also be a point of reference for discussion if the ratings are lower or higher than for similar consumers.

To log onto the DST: http://wdst.mhnocc.org/

Transfers

For mental health clinicians the concept of continuity of care and consumer pathways poses some challenges for the implementation of the NOCC consumer outcomes at ‘transfer’ points within the same age grouping. Particularly in the area of transfer:

• between teams/programs in a service setting
• from one service setting to another service setting.

In addition to the national protocol there are likely to be local business rules for collections and reviews undertaken when a consumer transfers within a setting or across a setting.

Within settings (for example Ambulatory–Ambulatory)

A number of consumers access multiple services across a variety of service settings within the same mental health service though arrangements differ across jurisdictions. Some consumers will access:

• Multiple services concurrently for example, a case managed/continuing care consumer may during periods of crisis also access a brief intensive crisis/assertive home based treatment.
• While others will move from one to the other for example moving from a case managed/ continuing care team to a longer term intensive treatment and rehabilitation team.

Where there is no change in setting such as a transfer within the ambulatory setting, consumer outcomes are not required.

However, the consumer outcomes provide longitudinal evidence of deterioration, lack of change or improvement which can be used to advocate for referral or acceptance into or out of specific programs. In addition to providing evidence for referral to a new or additional program, the consumer outcomes collection enables identification of outcomes as a result of interventions.

That is while there is no change in setting and no requirement for consumer outcomes a team/program could complete a consumer outcome review other (also known in some jurisdictions as ad hoc review or discretionary review) at entry into the team/program and again on exit from the program.

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Across settings (for example Ambulatory–Inpatient)

Embedding the NOCC protocol into clinical practice has been particularly difficult for existing consumers who move between settings such as Ambulatory to Inpatient. The rationale for collecting at this point is simple; there has been considerable change in the consumer’s presentation to warrant an admission where treatment is intensive and more restrictive.

There are some challenges for mental health clinicians in this protocol requirement, such as:

• Continuity of care and ongoing involvement of the case manager/key worker. That is the consumer has not been ‘discharged’ and therefore the requirement to complete discharge consumer outcomes is perceived as inappropriate or meaningless.
• Admission (and possible discharge in the case of a brief crisis admission) may occur without the case manager/key worker knowledge.

Most services have developed local business rules to assist clinicians in meeting this requirement of the collection protocol.

Statutory body

Mental health review board/tribunal

Mental health review boards/tribunals are usually established under the jurisdictional mental health legislation to conduct reviews of, and hear appeals by, psychiatric patients being treated involuntarily. Documentation processes and membership varies across jurisdictions.

To date the submission of consumer outcomes by clinicians to the Board or the Board’s request for consumer outcomes information has been limited. Given that consumer outcomes can validate and confirm a clinician’s position, they may increasingly be supplied to the Board. Additionally, as Boards and consumers become more aware of the availability of this information the request for inclusion is likely to increase. It is important to note that some consumers might be reluctant to identify areas of difficulty on the consumer self-assessment if these are being presented to the mental health review board/tribunals or in other courts.

Consumer outcomes are of value when:

• The recommendations proposed by the treating team are validated by the clinician measures.
• The mental health board/tribunals use the consumer self-assessment in the context of requesting specific information on collaboration/consultation with the consumer to ascertain their views/wishes as well as consideration of the guardian/family member or primary carers wishes.
• Multiple assessments are synthesised and mapped over time.

For example a consumer who is on a community treatment order receiving mandated treatment who rates themselves as having absolutely no problems might be at risk of deteriorating if the order is removed. When consumers become non-compliant with treatment, they may deteriorate, and risk relapse. Equally a consumer, who rates significant areas of distress while the clinician rates low, might be at risk of re-presenting if discharged.

Chief psychiatrists are appointed in each jurisdiction (except Tasmania and Northern Territory) with responsibility under the relevant mental health legislation to monitor statutory practices.

The roles vary but may include:

• Monitoring clinical standards of psychiatric practice and treatment provided by public mental health services.
• Responding to complaints from consumers, carers and others.

The Chief psychiatrist’s office could utilise consumer outcomes information to augment other clinical information provided or requested for consumers of mental health services.

Additional supports/external agencies

As part of the routine review of consumer’s needs and opportunities, most consumers of public mental health services will require referral to additional supports and external agencies.

Consumer outcomes can identify areas of difficulty and focus areas for intervention. Areas of difficulty often change and the consumer outcomes can provide a framework for identifying improvement which may not be immediately recognisable.

Group program

Consumers often access specific therapeutic or education group programs offered by the mental health service. There is usually no change in setting for existing ambulatory consumers, so consumer outcomes are not automatically required. Previous collections of consumer outcomes provide longitudinal evidence of deterioration, lack of change or improvement which can be used to advocate for referral or acceptance into or out of group programs.

In addition to providing evidence for referral to a new or additional program, the consumer outcomes collection enables identification of change following specific interventions. That is, while there is no change in setting and no requirement for consumer outcomes, a group coordinator could complete a review other (also known in some jurisdictions as ad hoc review or discretionary review) at entry and again at exit from the group program.
Clinical supervision

There are occasions when clinicians might benefit from a more comprehensive review of a particular consumer’s presentation, which could be explored in clinical supervision.

www.aasw.asn.au/adobe/publications/Practice%20Standards_Supervision.pdf

Refer to: 3.5 Supervision

Clinicians should encourage, support and facilitate a consumer requested review process.

The nationally available ‘Whose outcome is it anyway? Consumer Self-Assessment in Mental Health’ promotional materials state “It’s time to tell your side of the story. Everyone working together towards a better outcome for you” (Australian Mental Health Outcomes Classification Network, ‘Whose outcome is it anyway?).

It is reasonable for a consumer of public mental health services to request a formal review of their treatment and care by the:

• multidisciplinary clinical review
• mental health review board/tribunal
• Chief psychiatrist.

In addition to this a consumer may request a review and:

• revision of their individual care/service/recovery plan
• completion of their consumer outcomes.

3.4 Discharge

Discharge planning begins at the point of assessment. The decision to discharge a consumer from a service should be a clinical decision and made following assessment (ideally face-to-face) and collateral from key informants including the consumer.

National Outcomes and Casemix Collection (NOCC) discharge requirements

For all clinician rated measures clinicians need to refer to the individual measure rating guidelines.

In relation to the consumer self-assessment:

• Clinicians are also required to either offer or identify relevant temporary contraindication or exclusion criteria.
• Consumers can choose to complete the measure.

The collection requirements are articulated in the NOCC protocol:

National Outcomes and Casemix Collection: Technical Specification of State and Territory reporting requirements for the outcomes and casemix components of ‘Agreed Data’ under National Mental Health Information Development Funding Agreements Department of Health and Ageing, Canberra, 2002

There are some practical difficulties in collecting the mandated discharge measures when an existing ambulatory consumer is admitted to an inpatient unit or disengages from follow-up. Even when a consumer who has disengaged is discharged:

• This decision is usually made on the basis of second or third hand information, for example communication with a GP, family member, partner etc.
• The clinician rated discharge measures can be completed on all available information.
• If a clinician is unable to make an informed estimate of the severity/difficulty of an item on the basis of all available information, there is capacity to select an unable to rate option for the HoNOS or LSP-16. Coding (for example rating of 7 or 9) of these items is dependant on data system and jurisdiction option. It is important to remember that missing items may effect calculation of subscale and total scores depending on data system.

The consumer outcomes can help alleviate the natural fear that exists around discharge.

For example:

• For some consumers there is anxiety in being discharged from a mental health service to community supports and general practitioner and the consumer outcomes can longitudinally represent change and improvement and consequently allay the consumer’s fears.
• For some staff and family there is an anxiety in discharging a consumer from an acute inpatient unit. For some consumers there is a high level of difficulty and disability which is managed in the community continuously. For consumers who have multiple admissions, the outcomes can show that while the discharge rating is higher than the general population under care it is consistent for this consumer.

For more information on:

• offering the self-assessment go to Refer to: 2.2.1 Offering
• consumer self-assessment collection requirements Refer to: 2.2.1 Offering

3.5 Supervision

“9.20 The MHS ensures that staff have access to formal and informal supervision.

11.3.15 Staff of the MHS involved in providing assessment undergo specific training in assessment and receive supervision from a more experienced colleague” (National Mental Health Working Group, National Standards for Mental Health Services, December 1996).

Most clinicians have access to professional/clinical, operational supervision or a combination of these to facilitate competent and independent practice. A number of guidelines have been developed by specific professions in the area of supervision. The distinction between the different types of supervision are not clear and more often then not the areas explored are interrelated and the supervision is more a combination of both professional and operational. Generally though:

• Professional supervision provides a platform for reviewing professional standards, therapeutic approaches and the dynamics in the relationship between the consumer and clinician. It is usually undertaken with a senior of the same discipline.
• Operational/line management supervision provides a platform for reviewing role responsibility, practice standards, HR requirements and professional development as well as caseload monitoring. It is usually undertaken by the team leader or program manager.

“Supervision is most effective when it is valued by both the supervisor and supervisee, when both parties are motivated and able to give it a high priority, and where there is recognition of the rights and needs of the supervisee as an adult learner” (National Practice Standards of the Australian Association of Social Workers: Supervision, page 1, July 2000).

Illustrated in the examples below clinical supervision incorporates both operational and professional components.

Examples

Consumer outcomes could be used in supervision to:

• Identify profiles of consumers on case load by using tools, for example, consumer outcomes summary reports per consumer to assist in managing workload through understanding of intensity, complexity and interventions (e.g. consumer outcome collection history).
• Clarify and articulate the interventions/therapies being used for a particular consumer.
• Assess consumer outcomes - those that are improving (possible plans for discharge), those that are not improving (possible plans for referral or additional supports) as well as those who remain the same. It could also provide an opportunity to explore issues related to the offering of and engagement in meaningful dialogue on the consumer self-assessment measure.
• Discuss multidisciplinary perspectives on consumer’s presentation, interventions and outcomes.
• Identify alternative or complementary interventions/therapies for a particular consumer.
• Practice offering the consumer self-assessment (for example using the AMHOCN Clinical Utility Fidelity Checklist).
• Practice offering the consumer feedback on consumer outcomes (for example using the AMHOCN Clinical Utility Fidelity Checklist).
• Explore clinicians’ values and attitudes and their impact on therapeutic alliance.
• Explore clinicians’ values, beliefs and attitudes on consumer self-assessment process.
• Explore organisational values and attitudes and their impact on clinical practice.
• Identify training requirements and opportunities.

Suggested websites:

www.aasw.asn.au/adobe/publications/Practice%20Standards_Supervision.pdf

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