Use of a quality improvement strategy to increase drug and alcohol consultation and care opportunities for mental health inpatients in rural and remote New South Wales.

PROBLEM: Mental health inpatients have high rates of co-morbid substance use disorders which may exceed 50% in addition to the presenting complaint(s). Treating teams may prioritise, and substance use disorders are often not addressed. SETTING: Dubbo inpatient mental health units. KEY MEASURES FOR IMPROVEMENT: Rates of drug and alcohol consult of inpatients. DESIGN: Retrospective audit of all inpatient records for mental health units at Dubbo Hospital (May-October period 2018 and 2019) following the intervention. Qualitative reflections of clinical staff were also included. STRATEGIES FOR CHANGE: From early 2019, the problem was communicated with staff via education and open discussion. Modelling of the expected numbers of referral was understood as manageable within existing resources. The agenda of the morning meeting then always included an item that asked all team members to identify and refer a person if they needed drug and alcohol care. EFFECT OF CHANGE: Consultation by the drug and alcohol clinical nurse consultant increased from 48 of 228 (21%) patients in the 2018 period to 83 of 232 (35.8%) patients in the 2019 period. LESSONS LEARNT: The community and inpatient multidisciplinary team can correctly inform and increase drug and alcohol referral for mental health inpatients.

Use of a quality improvement strategy to introduce co-design of the mental health discharge plan in rural and remote New South Wales.

PROBLEM: Patients have not traditionally partnered in the design of their discharge plans, with discharge summaries at times not completed. In rural settings, discharge planning communicates care to a complex geographic area with fragmented resources. Patients may also be socially disadvantaged, with relatives and friends sometimes excluded. DESIGN: Situational analysis and liaison with key partners occurred in the months prior to the core project. Opportunities for improvement were noted. An audit of all discharges in May 2020 was planned to assess rates of discharge completion, co-design and inclusion of next of kin. Qualitative feedback was also noted from staff. SETTING: Dubbo inpatient mental health units (Gundaymarra and Barraminya). KEY MEASURES FOR IMPROVEMENT: Rates of discharge summary completion, co-design of discharge plan, engagement of next of kin. Qualitative measures included reflections of clinical staff involved. STRATEGY FOR CHANGE: Junior doctors were key in facilitating each patient to co-design their discharge plan and collaborate with all biological and psychosocial treatments and providers in a forum for open discussion. The inclusion of nominated next of kin was core. EFFECTS OF CHANGE: Discharge summary completion rates were high; co-design of discharge plans occurred frequently; and next of kin were involved with few exceptions. The adoption of the person as expert in modifying their plan became a norm. Medical staff wanted this care frame for each person. LESSONS LEARNT: Engaging patients and their next of kin directly in their discharge planning improves care opportunities in a rural setting, as well as understanding for all parties. This approach also prioritises the process of discharge completion.