An examination of risk factors for readmission to acute adult mental health services within 28 days of discharge in the Australian setting.

OBJECTIVE: The aim of this paper was to identify risk factors associated with readmission within 28 days of discharge from eight Australian adult acute mental health inpatient services. METHOD: A detailed file audit was conducted comparing 222 patients readmitted within 28 days of discharge with 253 patients not readmitted during the same period. RESULTS: There was an association between early readmission and having had contact with the service in the previous 12 months (51% vs 21%), having been admitted in the previous 12 months (65% vs 36%), and having been diagnosed with an emotionally unstable personality disorder (14% vs 4%). Those who were not readmitted had a significantly higher score in the Health of the Nation Outcome Scales on index admission than those who were readmitted. Those who had community team contact on the day of discharge and those who received follow up by the mental health team within 7 days of discharge were more likely to be readmitted (55% vs 45% and 29% vs 19% respectively). CONCLUSIONS: Significant determinants of early readmission identified were a history of recent previous admissions and a diagnosis of unstable personality disorder. The usefulness of this performance measure to Area Mental Health Services and clinicians is discussed.

Forming and sustaining partnerships to provide integrated services for young people: an overview based on the headspace Geelong experience.

AIM: To discuss critical considerations in the formation and maintenance of agency partnerships designed to provide integrated care for young people. METHODS: Two years after its establishment, an evaluation of the headspace Barwon collaboration and a review of the health-care and management literature on agency collaboration were conducted. The principal findings together with the authors' experience working at establishing and maintaining the partnership are used to discuss critical issues in forming and maintaining inter-agency partnerships. RESULTS: Structural and process considerations are necessary but not sufficient for the successful formation and maintenance of inter-agency partnerships and integrated care provision. Specifically, organizational culture change and staff engagement is a significant challenge and planning for this is essential and often neglected. CONCLUSIONS: Although agreeing on common goals and objectives is an essential first step in forming partnerships designed to provide integrated care, goodwill is not enough, and the literature consistently shows that most collaborations fail to meet their objectives. Principles and lessons of organizational behaviour and management practices in the business sector can contribute a great deal to partnership planning.

It's not that bad: the views of consumers and carers about routine outcome measurement in mental health.

The mandatory use of routine outcome measurement (ROM) has been introduced into all public sector mental health services in Australia over the past 6 years. Qualitative processes were used to engage consumers and carers in suggesting how the measures can be used in clinical practice. The project involved an audit by survey, followed by a range of interactive workshops designed to elicit the views of consumers, carers and clinicians, as well as to involve all parties in dialogue about ROM. In addition, there was engagement of consumers and carers in the training of clinicians in the clinical use of ROM, and in the production of promotional materials aimed at informing consumers and carers about ROM. When consumers and carers have had an opportunity to be involved in ROM they have found it a useful experience, and those who had not been involved can see the potential. Consumers and carers indicated that they believe the greatest opportunity arising from the suite of measures is the use of the consumer self-assessment measure the Behaviour and Symptom Identification Scale (BASIS-32).

A descriptive interview with 64 patients discharged from an acute-psychiatric-inpatient service.

BACKGROUND: Acute-mental-health services receive hundreds of admissions every year. Some of these patients will continue to be case-managed by community mental-health teams on discharge from the acute unit while others will not remain in contact with the mental-health service. This study compares the findings of comprehensive interviews conducted with current and past patients of the community mental-health service 3 or more years following case closure from the community ambulatory service. METHODS: Between 1 July 1999 and 30 June 2001, there were 2245 closed cases identified at Barwon Health. Letters of invitation to participate in a research project were sent to people who had suffered from psychotic illnesses, and had been case-closed by community mental-health services between the above dates and had not been in contact with the Community and Mental Health Service for at least 6 months. A second group of participants was recruited from people who had also been case-closed by community mental-health teams in Barwon Health during the 1999-2001 2-year-time window but whose cases had been re-opened and who were in case management with Barwon Health at the time of the study. All participants were interviewed using the Diagnostic Interview for Psychosis. RESULTS: Letter responses were received from 17 men and 18 women, aged 40.7 +/- 12.0 (mean +/- SD), who were interviewed. A second group of 17 men and 12 women, aged 40.9 +/- 9.6 (mean +/- SD) of currently case-managed patients was interviewed. All interviewees reported a detailed history of mental illness. Persistent social dysfunction and impaired quality of life were reported in both groups. CONCLUSION: Patients suffering from psychotic disorders who had been case-closed by community mental-health teams and had been discharged to the care of their general practitioners or elsewhere continued to show evidence of significant impairment due to mental illness 3 years after being case-closed.

The validity of the CGI severity and improvement scales as measures of clinical effectiveness suitable for routine clinical use.

OBJECTIVE: The Clinical Global Impression Scale (CGI) is established as a core metric in psychiatric research. This study aims to test the validity of CGI as a clinical outcome measure suitable for routine use in a private inpatient setting. METHODS: The CGI was added to a standard battery of routine outcome measures in a private psychiatric hospital. Data were collected on consecutive admissions over a period of 24 months, which included clinical diagnosis, demographics, service utilization and four routine measures (CGI, HoNOS, MHQ-14 and DASS-21) at both admission and discharge. Descriptive and comparative data analyses were performed. RESULTS: Of 786 admissions in total, there were 624 and 614 CGI-S ratings completed at the point of admission and discharge, respectively, and 610 completed CGI-I ratings. The admission and discharge CGI-S scores were correlated (r = 0.40), and the indirect improvement measures obtained from their differences were highly correlated with the direct CGI-I scores (r = 0.71). The CGI results reflected similar trends seen in the other three outcome measures. CONCLUSIONS: The CGI is a valid clinical outcome measure suitable for routine use in an inpatient setting. It offers a number of advantages, including its established utility in psychiatric research, sensitivity to change, quick and simple administration, utility across diagnostic groupings, and reliability in the hands of skilled clinicians.

Consumer attitudes towards the use of routine outcome measures in a public mental health service: a consumer-driven study.

In this study conducted by consumer consultants, 50 consumers who have a Barwon Health case manager (the majority of whom were nurses) were interviewed using a structured questionnaire to ascertain their attitudes towards the routine use of outcome measures. Forty participants (80% of those interviewed) reported they had been offered the Behaviour and Symptom Identification Scale (BASIS-32) to complete in routine care by their case managers and of those, 95% (n = 38) completed it. On those who completed the BASIS-32, 42% said their case manager had explained what the BASIS-32 would be used for, 45% said that the case manager had discussed their responses with them, 76% stated that completing the BASIS-32 had helped the case manager to understand them better and 66% believed that completing the BASIS-32 had led to them receiving better care. Only 30% of the group interviewed were aware that their case manager regularly completed a Health of the Nation Outcome Scales and Life Skills Profile. Feedback about the process of completing the BASIS-32 was obtained as well as suggestions on how the process may be improved. The results indicate that consumers see the benefit of routine outcome measurement and believe it leads to improved care. More information about outcome measures, including the clinician-rated outcome measures, needs to be provided to consumers if they are to be engaged constructively in this exercise.

Monitoring the safe use of clozapine: a consensus view from Victoria, Australia.

Clozapine is an important antipsychotic agent that has a unique profile of clinical benefits, but that has also been associated with several serious and potentially life-threatening safety concerns. In order to minimise the impact of haematological adverse events, health professionals treating patients with clozapine are currently required to register their patients on a centrally administered data network and to conform to strict protocols. The consensus statement documented in this article extends existing protocols by recommending monitoring of patients treated with clozapine for additional adverse effects during treatment. This consensus statement reflects the current practice at five major public psychiatric hospitals in Victoria, Australia, for the monitoring and management of clozapine-related adverse events, and has been implemented at these sites because of emerging safety concerns associating clozapine with cardiovascular and metabolic adverse effects.

The validity of the 21-item version of the Depression Anxiety Stress Scales as a routine clinical outcome measure.

OBJECTIVE: This study aimed to test the validity of the 21-item Depression Anxiety Stress Scales (DASS-21) as a routine clinical outcome measure in the private in-patient setting. We hypothesized that it would be a suitable routine outcome instrument in this setting. METHOD: All in-patients treated at a private psychiatric hospital over a period of 24 months were included in the study. Data were collected on demographics, service utilization, diagnosis and a set of four routine measures both at admission and discharge. These measures consisted of the Clinical Global Impressions (CGI) scales, Health of the Nation Outcome Scales (HoNOS), the Mental Health Questionnaire (MHQ-14) and DASS-21. The results of these measures were compared. RESULTS: Of 786 admissions in total, the number of fully completed (ie paired admission and discharge) data sets for the DASS-21 depression, anxiety and stress subscales were 337, 328 and 347, respectively. All subscales showed statistically significant reductions in mean scores from admission to discharge (P < 0.001) and were significantly correlated with all MHQ-14 subscales and significantly related to CGI scale categories. The total DASS-21 and total HoNOS scores were also significantly correlated. CONCLUSIONS: The findings from the present study support the validity of DASS-21 as a routine clinical outcome measure in the private in-patient setting.

Routine outcome measurement in public mental health: results of a clinician survey.

This paper explores the attitudes of mental health workers in one public mental health service towards the implementation and use of routine outcome measurement. Two years after their introduction into routine clinical practice, there were equal numbers of positive and negative observations from clinicians about the clinical value of the clinician-rated outcome measures, while more positive observations were made about value of the consumer-rated outcome measure. The most frequent observation from clinicians in relation to making outcome measures more useful to them in clinical practice was that more training, particularly refresher training, is needed. In addition, clinicians indicated that more sophisticated support which assists them to understand the meaning and possible use of outcome measure ratings is required.

Interdisciplinary teamwork and leadership: issues for psychiatrists.

OBJECTIVE: To review the constructs and applications of interdisciplinary teams in mental health services, with a particular view to ascertaining the most effective types of teams and their leadership. METHOD: Some of the most challenging questions from a psychiatrist's viewpoint regarding the functions of interdisciplinary teams in the mental health service are addressed. RESULTS: The effectiveness of the interdisciplinary team in mental health services is supported by an extensive literature that is much more qualitative and descriptive than quantitative and empirically rigorous, except as part of packages of variables subjected to randomized controlled trials. CONCLUSION: Effective interdisciplinary teamwork in mental health services involves both retaining differentiated disciplinary roles and developing shared core tasks. It requires sound leadership, effective team management, clinical supervision and explicit mechanisms for resolving role conflicts and ensuring safe practices. No one profession should hold a monopoly on leadership.

Using continuous quality improvement to implement a clinical governance framework in a mental health service.

OBJECTIVES: To outline the principles of continuous quality improvement that can be utilized to develop a clinical governance framework in a mental health service. CONCLUSIONS: The term clinical governance is used to describe the framework through which health organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care. Implementing a clinical governance framework requires clear leadership, particularly clinical leadership, the development of structures and processes to facilitate communication and the development of systems for monitoring and evaluating services. Effective implementation can be supported by the development of an open culture that promotes organizational learning from experience and supporting innovation.

Organizational change management in mental health.

OBJECTIVE: To discuss change management as applicable to mental health. CONCLUSIONS: As mental health care grows increasingly complex, and the network of accountability widens, change is both inevitable and necessary. Strategies to introduce change effectively are essential. Resistance by medical staff to change often has a sound basis and must be acknowledged and explored. Change in clinical systems and practice is facilitated by careful planning and preparation, and by engaging clinicians in all phases of the change process; change will fail if this is not achieved. A number of management models facilitate the understanding and process of change.

Quality, risk management and governance in mental health: an overview.

OBJECTIVE: To consider the origin, current emphasis and relevance of the concepts of quality, risk management and clinical governance in mental health. CONCLUSIONS: Increasingly, health service boards and management teams are required to give attention to clinical governance rather than corporate governance alone. Clinical governance is a unifying quality concept that aims to produce a structure and systems to assure and improve the quality of clinical services by promoting an integrated and organization-wide approach towards continuous quality improvement. Many psychiatrists will find the reduction in clinical autonomy, the need to consider the welfare of the whole population as well as the individual patient for whom they are responsible, and the requirement that they play a part in a complex systems approach to quality improvement to be a challenge. Avoiding or ignoring this challenge will potentially lead to conflict with modern management approaches and increased loss of influence on future developments in mental health services.

Reflections on clinician leadership and management in mental health.

OBJECTIVE: To review the role of clinician leadership in the management of mental health services. CONCLUSIONS: The literature suggests that clinician leadership is increasingly regarded as an essential element in the effective introduction of innovation and improved quality of clinical care by those who manage mental health services. Psychiatrist leaders have a role to play in ensuring that service change and innovation is based on sound clinical values, is developed in partnership with clinicians and is understood and supported by psychiatrist colleagues. Clinician leaders require clear vision, commitment and courage. The support of their colleagues is essential if the psychiatric profession is to have influence on future development of mental health services.

Providing integrated mental health services: a policy and management perspective.

OBJECTIVE: To review the challenge of providing integrated mental health services from a policy and health management perspective. CONCLUSIONS: The provision of integrated mental health services involving specialist mental health services, general practitioners, psychiatric disability and rehabilitation services and public community health services is a major challenge in the Australian health care context and is increasingly an expectation of the community. Government, Divisions of General Practice and public community health policy and many Government, State and local initiatives have attempted to address this challenge. However, much remains to be done, including culture change within services and professions and the development of technology to support integrated service provision.