South Adelaide Local Health Network

Acute Mental Health Services

Model of Care

Draft

Addendum: SA Health Model of Care for Major Hospitals

February 2018

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Document Information Document Owner: Director: Mental Health Title: Mental Health Description: Model of Care Subject: Acute Services Mental Health Model of Care Document Location:

TBA

Document History Revision History

Date Version Approved by Change Reference 29/12/2017

V1 Draft Steering group

16/1/2018

V2 Draft Steering group

Consultation History

Date Title

16/1/208 First draft consultation with Head of Units, NUMS/NC, Allied Health, Psychiatric Consultants and Consumer reprensenatives.

Endorsement

Date

Acknowledgements:

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Thank you to everybody who contributed to this document.

Table of Contents Document Information ........................................................................................................................... 2

Document History ................................................................................................................................... 2

Hope ........................................................................................................................................................ 5

Background ............................................................................................................................................. 6

Traditional land of the Kaurna People .................................................................................................... 7

Acronyms and Initialisms ........................................................................................................................ 8

1. Purpose and Scope .............................................................................................................................. 9

1.2 Cultural Awareness ..................................................................................................................... 10

1.3 Legislative, Policy Directives and Frameworks ........................................................................... 10

2. Model of Care ................................................................................................................................... 11

2.1 Principles ..................................................................................................................................... 11

3. Patient Centred Care ......................................................................................................................... 12

3.1. Safe Care: ................................................................................................................................... 13

3.2. The Healing Environment........................................................................................................... 14

3.3. Treating the Whole Patient ........................................................................................................ 14

3.3.1 Recovery in Acute Mental Health Care ................................................................................ 15

3.3.2 Carers ................................................................................................................................... 16

3.3.3 Advanced Care Directives (ACD) .......................................................................................... 16

3.4. Patient Journey .......................................................................................................................... 17

4. Components of Acute MH Services .................................................................................................. 18

4.1 Access .......................................................................................................................................... 18

4.3 Short Stay Unit (SSU) ................................................................................................................... 19

4.4 Adult and Older Persons Acute Inpatient Units (IPU) ................................................................. 19

4.5 Psychiatric Intensive Care Units (PICU) ....................................................................................... 20

4.6 Adult Psychiatric High Dependency Units (HDU) ........................................................................ 21

4.7 Older Persons High Dependency Unit (HDU) .............................................................................. 21

5. Contemporary Evidence Based Practice and Approaches: ............................................................... 22

5.1 Trauma-Informed Approach ....................................................................................................... 22

5.2 Minimise Restraint and Seclusion ............................................................................................... 22

5.3 Connecting with People .............................................................................................................. 23

5.4 Therapeutic Interventions .......................................................................................................... 23

5.5 Solution Focussed Approach ....................................................................................................... 23

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5.6 Hearing Voices Approach ............................................................................................................ 23

5.7 Accredited Assistance Dogs and Animal Assisted Activity .......................................................... 24

5.8 Motivational Interviewing ........................................................................................................... 24

5.9 Potential Future Innovations: ..................................................................................................... 24

5.9.1 Safewards: ............................................................................................................................ 24

5.9.2 Accredited Exercise Physiologists ........................................................................................ 25

6. Multidisciplinary Workforce ............................................................................................................. 25

7. Efficiency and Effectiveness .............................................................................................................. 26

7.1 Clinical Governance ..................................................................................................................... 26

7.2 Localised Bed Management. ....................................................................................................... 26

7.3 Electronic Journey Boards (EJB) .................................................................................................. 26

7.4 Outcome measurement .............................................................................................................. 26

7.5 Key Performance Indicators ........................................................................................................ 27

7.6 Discharge planning ...................................................................................................................... 27

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Hope

Black hole! Funny that!

Black was always my favourite choice. Clothing, cats, hats and mats

I always felt good in Black

Black hole! Not my favourite place! No hope, no use, no future, no way out

I’ve reached the bottom of this black bit with a Bang!

Might just as well drown in this inescapable black numbness.

Give up! Stay here! Warmed by my own tears.

Alone! I look around. What do I see?

Black nothingness – like Jonah in the whale

Swallowed by the Black Dog of despair, hopelessness and sadness.

Suffocated by my feelings. Trapped by my thoughts

Worthless! Hopeless! Who cares?

Does Anybody Care? Somebody does! They are in this pit with me. I feel them trying to push with me upward

I look up. I sense help is reaching down to me.

I hear. “We care! We are here for you! Reach out!”

I feel! I Hope!

I reach out and slowly start climbing!

Vicki Donohue August 2017

(Permission provided)

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Background The delivery of mental health services to people has been widely accepted across jurisdictions to be committed to treating and caring for people as far as possible in the community (UN Principles for the Protection of Persons with Mental Illness, 19911). At times, when the acuity of a person’s mental illness and/or concerns for harm increase, the need to offer an expanded range of services may arise. This will often include services which are offered from a hospital base, involving emergency departments, short stay units and inpatient wards as part of stepped levels of care meeting the needs of the individual. Acute hospital-based mental health services are one component of an integrated system of care, necessitating clear pathways between each component to support a person across the continuum and their connections with core relationships and roles in the community. Southern Adelaide Local Health Network (SALHN) Mental Health provides a range of integrated services across community and hospital settings, targeted at all ages from adolescence to the older person, in collaboration with non-Government organisations and General Practice Network South. The SALHN regional area covers a population catchment of 422,6942. In the 2016-2017 financial year there were 4,7503 mental health presentations to SALHN Emergency Departments, and 3,3174 were discharged from hospital within SALHN with mental health concerns. The SA Health Model of Care for Major Hospitals was developed within the Transforming Health reform of South Australian health services. In the absence of a previous SALHN Acute Mental Health Services model of care, the SALHN Acute Model of Care was developed to ensure a mental health specific focus on acute service delivery within a national mental health reform process and a commitment to best outcomes and person-centred care.

1 Mental Health Act 2009 (SA). 2 ABS Census, 2016 3 Emergency Department Data Collection 4 Integrated South Australian Activity Collection

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Traditional land of the Kaurna People

SA Health would like to acknowledge that the land SALHN Mental Health Services are located on is the traditional lands for the Kaurna people and we respect their spiritual relationship with this country. We also acknowledge the Kaurna people as the custodians of the greater Adelaide region and their cultural and heritage beliefs are still as important to the living people today. SA Health also acknowledges this Model of Care provides care for patients who originate from other transitional lands across all of Australia.

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Acronyms and Initialisms

SA Health South Australian Department of Health

SALHN South Adelaide Local Health Network

MH Mental Health

MHA Mental Health Act 2009

MoC Model of Care

FMC Flinders Medical Centre

ED Emergency Department

NH Noarlunga Hospital

SSU Short Stay Unit

MTC Margaret Tobin Centre

OPMHS Older Person Mental Health Service

EBP Evidence Based Practice

ACD Advanced Care Directives

CL Consultation and Liaison

IPU Inpatient Unit

PICU Psychiatric Intensive Care Unit

HDU High Dependency Unit

PPP Personal Prevention Plans

ECT Electroconvulsive therapy

CBT Cognitive Behavioural Therapy

ACT Acceptance and Commitment Therapy

DBT Dialectal Behavioural Therapy

NSQHS National Safety Quality Health Standards

EJB Electronic Journey Boards

BAS Bed Allocation System

KPI Key Performance Indicators

EDD Estimate Discharge Date

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1. Purpose and Scope The purpose of this document is to provide an overarching framework for the provision of a safe and high quality mental health services within an acute care setting. The document outlines a framework of core policies, principles and evidence-based approaches which underpin the Model of Care for Acute Mental Health Services within SALHN. The model will inform further development of operational pathways and processes of care, treatment and recovery.

‘Working together for a healthier state of mind’5

Acute Mental Health Services currently provide assessment, care and treatment for people from the age of 18 years of age. Acute mental health services include delivery of services from:

• Emergency Department (ED) - Flinders Medical Centre (FMC) and Noarlunga Hospital (NH)

• FMC Short Stay Unit (SSU)

• Inpatient Units: Two overflow beds in 4GP, Margret Tobin Centre (MTC), Ward 18V Older Persons Mental Health Services (OPMHS) in FMC and Morier Ward (NH).

Other services which are part of acute mental health services but not in scope for this document include:

• Inpatient Units: Jamie Lacombe Centre and 4GP Eating Disorder and gambling beds

• Psychiatric Consultation and Liaison Service FMC and NH. SALHN Acute MH services sit within a larger stepped system of care tailored to the varying needs of individuals, level of health acuity, and stage of recovery.

Acute MH services typically assess and provide care within a hospital setting and support all consumers to return to community living in a smooth and timely manner. They work in close collaboration with carers, general hospital based services, emergency services, a spectrum of general and speciality community mental health teams, primary health care and other service providers involved in supporting consumers in the community.

This MoC is based on accepted best practice approaches to effective access, assessment, risk management and clinical interventions. Consumer and carer groups were asked on their preferred term to be used in this documents i.e. patient, consumer or client. An outstanding response was to use the term patient if referring to a person who has been admitted to a hospital and consumer, participant or client when referring to someone in the community who accesses community mental health services.

5 SALHN Mental Health Vision Statement 2014

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1.2 Cultural Awareness Aboriginal People

Health outcomes for Aboriginal and Torres Strait Islander people differ significantly from those of the wider community. It is well documented that Indigenous people experience significantly shorter life expectancy, higher rates of infant mortality and more avoidable deaths.6 These disparities exist in the incidence of mental health conditions, outcomes, the social determinants of health, and the way that people access and use mental health services. Aboriginal people function from the perspective of wellness as opposed to illness. The delivery of care will take into account the special relationship to family, community and country and the significant sense of loss, grief and trauma form past and current events that many Aboriginal and Torrens Strait Islander people experience. Aboriginal and Torrens Islanders will have access to interpreters and traditional healers when accessing acute mental health services.

Culturally and Linguistically Diverse (CALD) People

Australia’s community demonstrates broad and evolving ethnic diversity and SALHN Acute MH services recognise the importance of culture and the differences between people. We will provide services that are both culturally and linguistically appropriate which is respectful of peoples, language, food, family, religion and spiritual needs. The delivery of care will recognises the importance of culture and the migration experience of consumers, carers and families of culturally linguistic and diverse backgrounds.

1.3 Legislative, Policy Directives and Frameworks In developing a MoC for Acute MH Services the following legislation, policies, plans and frameworks have been considered -

> Fifth National Mental Health Plan 2017 > National Safety and Quality Health Service Standards (second Edition) July 2017 > National Framework for Recovery-Orientated Mental Health Services 2013 > National Practice Standards for the Mental Health Workforce > SA Health Mental Health Services Pathways to Care Policy Directive 2014 > SA Mental Health Act 2009 > SA Guardian and Administration Act 1983 > Carers Recognition Act 2005 > The SA Health Safety and Quality 2017-2019 Workplan > Partnering with Cares Strategic Action plan 2017-2020 > SA Suicide Prevention Plan 2017-2021

6 National Mental Health Commission. Equally Well Consensus Statement: Improving the physical health and wellbeing of people living with mental illness in Australia. Sydney NMHC, 2016

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2. Model of Care A Model of Care ‘broadly defines the way health services are delivered. It outlines best practice care and services for a person or population group or patient cohort as they progress through the stages of a condition, injury or event’.7 It is ‘an overarching design for the provision of a particular type of health care service that is shaped by a theoretical basis, EBP (Evidence Based Practice) and defined standards’.8

2.1 Principles The MoC is defined by the numerous national, state and local plans, policies and frameworks pertaining to health provision and specifically to mental health. The model of care aims to support a health system so that:

> It encompasses a whole of system design > Care is integrated across disciplines, sectors and organisations > Patients are at the centre of the system > Patient and carer feedback will be considered in shaping the future > Evidence informs decisions and practice > The workforce is supported to become more flexible and involved in shaping the

future > The hospital and other settings will be a learning environment > Partnerships with other providers, universities and other key stakeholders will be

actively promoted.9 The SA Health MoC for major hospitals describes the key elements that must underpin SALHN Acute MH service:

> Providing safe care > Providing a healing environment > Treating the patient as a whole > Understanding the patient journey.

These core principles are supported by care delivery that is: > Patient centred > Based on evidence > Provided by a skilled workforce.

7 Agency for Clinical Innovation, 2013, Understanding the process to develop a model of care: An ACI Framework. 8 Davidson P, Halcomb E, Hickman L, Phillips J, Graham B. BEYOND THE RHETORIC: WHAT DO WE MEAN BY A ‘MODEL OF CARE’? Australian Journal of Advanced Nursing 2006 Volume 23 Number 3 pp 47-55 9 SA Health Model of Care for Major Hospitals

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Diagram 1 Model of Care for Major Hospitals SA Health

3. Patient Centred Care The model of care will promote a patient centred approach where patients will be actively involved in their care and include people who patients want involved. Patient centred care is:

> Care that is safe and high quality and patients can access care when they need it > Making sure that healthcare staff respect and respond to patient choices, needs and

values > It has been described by some people with a lived experience as an attitude with the

ability to ‘stand in someone’s shoes’ > About forming the partnerships, working in collaboration and building relationships

with patients and their families, carers and other healthcare providers involved with the patient

> Being authentic and present with patients and carers > Use of therapeutic tools which encourage participation > Being respectful at all times > Communication (verbal and nonverbal) is non-judgemental and fosters safe

conversations.

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3.1. Safe Care: The philosophy of achieving safer, more effective and more responsive care for consumers is underpinned by the National Safety and Quality in Health Service Standards (NSQHS) 2017 (2nd ed.)10 Safety and Quality is an on ongoing process of reviewing incidents and practice and continually improving within an open disclosure framework. Robustly auditing practice against policy and procedures will ensure a continuous improvement cycle is embedded as a process.

The principles of the Mental Health Act 2009 identified in the Plain Language Guide11 to assist in the interpretation of the Act, also underpins mental health service provision in a safe and respectful manner;

> Care will be provided on a voluntary basis where possible > Place as little restriction as possible on the rights and freedom of a person with a

serious mental illness while meeting public and patient safety > Be delivered by comprehensive treatment and care plans that are developed in a

multi-disciplinary framework in partnership with the person and their family or other carers or supporters

> Take into account the different developmental needs throughout the lifespan > Take into account the different cultural and linguistic diversity of patients > Take into account Aboriginal or Torres Strait Islander descent, including traditional

beliefs and practices and, when practicable and appropriate, involve collaboration with health workers and traditional healers from their communities

> Conduct regular medical examinations of every person’s mental and physical health and regular medical review of any order applying to the person

> Only use medication for therapeutic purposes or safety reasons and not as a punishment or for the convenience of others

> Only use mechanical body restraints and seclusion as a last resort for safety reasons and not as a punishment or for the convenience of others

> Provide the person (together with their family or other carers or supports) with comprehensive information about their illnesses, any orders that apply to them and their legal rights. They also need to be provided information on treatment options and ensure as far as practicable that it can be understood by those to whom it is provided to.

Safe care allows participation of patients and carers in the persons care planning and treatment options and ensuring care and treatment is delivered in a manner that respects people’s uniqueness.

10 Australian Commission on Safety and Quality in Health Care. DRAFT National Safety and Quality Health Service Standards (second edition). Sydney (Au); 2017. 11 Department of Health, Mental Health Unit. Plain Language Guide, Mental Health Act 2009.

Safe care to the Inner, Outer South and Older Persons Consumer and Carer group meant:

Care which is non-judgmental (can have safe conversations), being respected as a person, people listening to me, people (staff) having compassion, involving people who I want in my care and receiving written information (on medication, about my discharge,

about my options)…October 2017

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3.2. The Healing Environment Assessment, care and treatment will be provided in welcoming environments that cater to the needs of people regardless of ethnicity, social, cultural or religious background, spirituality or sexual orientation.

Notwithstanding budgetary constraints we will attempt to bring existing facilities as close as practically possible to the standards of new buildings:

> Single rooms > Natural light > Designed to facilitate sexual safety12 > Sensitive to address LGBTQ issues > Provision of spaces and equipment to allow emotional self-regulation through

sensory modulation13 > Family friendly spaces.

When we are working within our existing facilities we will adapt and maximise our efforts to provide environments which facilitate healing and recovery.

3.3. Treating the Whole Patient Treating the patient as a whole recognises not only the patient’s mental wellbeing but also their physical health. People with mental illness have poorer physical health and people with psychosis die between 14 and 23 years earlier than the general population14. While people are with acute MH services for a relatively short period it is important to identify physical health needs for follow up and ensure referrals are made to the appropriate outpatient or community service.

A holistic and inclusive approach, focused on the mental, physical, occupational, social and emotional wellbeing of the individual and families is essential. Individuals’ lived experience is valued and Acute MH Service adopts holistic frameworks such as the biopsychosocial approach to care amongst others specific to discipline specialities.

Recognition and respecting aspects of different approaches lends itself to assessing the person as a whole. The multi-disciplinary treatment team partners with the patient and their carer(s) to develop individualised treatment plans.

12 NSW Sexual Safety of Mental Health Consumers Guidelines. 12-Nov-2013 13 Mental Health Restraint and Seclusion Toolkit Fact Sheet 6 14 National Mental Health Commission. Equally Well Consensus Statement: Improving the physical health and wellbeing of people living with mental illness in Australia. Sydney NMHC, 2016

I have never been in a mental health ward before and I was very scared…. Everybody – ward clerks, the doctors, nurses and social worker are very professional and caring..I felt I was treated with respect and

positivity. I don’t want to be here again but would encourage anyone with mental health (issues) to seek help.

Written by a Patient: Short Stay Unit, FMC October 2017

Case note review identified multi-disciplinary approach, safety planning and involvement of family of patient’s choosing and collaborative discharge planning.

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3.3.1 Recovery in Acute Mental Health Care The National Framework for Recovery-Orientated Mental Health Services is based upon a definition of recovery as ‘being able to create and live a meaningful and contributing life in a community of choice with or without the presence of mental health issues.’15 Enacting recovery principles allows:

> Building hope > Greater consumer choice promoting autonomy and self-determination > Working in collaborative partnerships, and meaningful engagement > Empowerment of consumers and carers by providing information and building on

existing strengths > Promoting citizenship.

The MoC will support the shift from a problem-oriented approach, which can be disempowering for patients and their support network, to an approach which focus on a person’s strengths and considers the views of individuals and their carer(s) who experience mental illness. This shift is fundamental to the outcomes of this document. Some examples on how we can achieve this goal is16:

Recovery Domain Practical example Creating/supporting hope -Things can change!

Collaborative care planning Narrative discussions with the patient Be future focused

Promoting autonomy and self determination -This means having choice!

Construct a safety plan based on what works Develop a plan together for de-escalation based on what works.

Collaborative partnerships and meaningful engagement - Be flexible!

Set up multidisciplinary decision making forums with the patient and family present. Engage in a robust admission orientation to unit. Micro communication with the patient (build trust, rapport, validate, affirm, corridor conversation)

Strength perspective - What’s working?

Linking to peer support workers, be future focused to draw on exiting skills and resources

Holistic and personalised care -if patients are involved, more likely it will work

Sensory modulation, safety planning Involve family and carers/friends

Citizenship -Active participation

Create and maintain clean living space on unit, do laundry, engage community care coordinators to continue to see in IPU

15 National Framework for Recovery-Orientated Mental Health Services: Guide for practitioners and providers Commonwealth of Australia 2013

16 Adapted from: McKenna B, Furness T, Dhital D, Houghton J. Adapted from Recovery-Orientated Care in Acute Inpatient Health Settings: An exploratory study. Issues in Mental Health Nursing July 2014 p528

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SALHN Acute services will work in collaboration with people to identify strengths and personal recovery goals. The person’s wellness journey will be supported through a range of intervention strategies.

To all the staff in Morier Ward, thank you from the very bottom of my heart for helping me during the past 2 weeks. I might not be here right now if it wasn’t for all of you, and the help I’ve received….I

can’t thank you enough

September 2017 from a patient and their family

Some of the approaches used as reflected in case note entries: Solution Focused and Sensory Modulation Group Work, Connecting with People Tools, Conversations with lived experience worker,

occupational therapy and psychology discipline specific and referral to the Recovery College

3.3.2 Carers SALHN Acute MH is committed to improving the way we partner with carers, and recognises the role of carers in health care:

> Carers are partners in care > Carers can be an advocate for the person they care for > Carers can be patients and users of the health system > Carers can be representatives of both carers and patients in the health system.17

Supportive relationships are essential to an individual’s mental health recovery. While receiving assessment and treatment in Acute MH services there is an ongoing need to continue to develop and maintain relationships with families, carers, friends and significant others.

Research demonstrates that the carer role has a physical and psychological impact and it is important that carers are supported by our workforce and connected with agencies that can support them when the patient leaves Acute MH services. This practice is consistent with the principle that carers have rights to recognition and access to support as articulated in the Carers Recognition Act 2005.

3.3.3 Advanced Care Directives (ACD) Patients may come into SALHN Acute MH with ACDs naming a substitute decision maker(s) and/or with expressed decisions made about their health. Existing ACDs will be identified as part of the assessment and admission process and stored in medical records. Staff will advise patients and carers on how to develop ACDs for the future.

17 SA Health Partnering with Carers Strategic Action Plan 2017 - 2020

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3.4. Patient Journey The patient journey describes how patients move through the system (Patient Flow). It supports the notion that the pathways support the patient receiving the right care, in the right place, at the right time, all the time.

The keystones to the hospital Patient Journey are to:18

> Provide access to the hospital that incorporates several access points and processes to facilitate a streamlined patient flow to the most appropriate point of care

> Ensure that the patient and their carers are at the centre of decision making > Recognise the different pathways and processes that best support planned and

unplanned episodes of care > Identify key clinical decision points including decision to admit, initiation of treatment

plan and intervention > Incorporate evidence-based care and implement best practice in acute clinical care

utilising clinical protocols > Implement workforce reform including staffing models to support appropriate clinical

decision making at key points > Ensure access to appropriate clinical support across the journey (imaging, allied

health, pharmacy, infection control etc) > Utilise flexible, acuity-adaptable inpatient areas > Link to Patient Pathways that apply across the continuum of the health system.

Diagram 2 - The Patient Journey19

18 SA Health Model of Care for Major Hospitals 19 Mental Health Directorate Model of Care New RAH Addendum: SA Health Model of Care

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4. Components of Acute MH Services

4.1 Access Emergency Departments provide a point of triage, assessment and for many will also involve the commencement of care. Direct admission pathways into Short Stay Unit or an inpatient bed are available if indicated following an assessment by Community Mental Health Services.

If consumers self-present to an ED and are deemed to require specialist mental health assessment, they will be supported by the Mental Health Consultation Liaison Service within the ED. If the person is linked to Community MH service, MH Consultation Liaison will attempt to contact the care coordinator at the earliest point in time to develop a collaborative plan.

Patients with a non-mental health condition requiring priority assessment and treatment will be provided mental health services by Consultation and Liaison Psychiatry while in a general hospital bed and may transfer to a mental health bed when appropriate. The patient must be fit for medical discharge to home before they are transferred to a mental health bed. Older people presenting with acute mental health issues including complex and severe dementia-related behaviours often have medical conditions that contribute to, precipitate or are co-morbid to the mental health condition. Pathways into OPMHS beds rely on these organic conditions being managed and stable, and nursing care acuity being appropriate, prior to admission. Specialised Psychogeriatric Consultation-Liaison clinicians are available to support general hospital teams. SALHN OPMHS at FMC admits people from a large proportion of country South Australia and transfers community management back to local community mental health teams at the end of the inpatient episode of care. Pathways for all consumers will be identified in detail in clinical handbooks and clear workflows will be identified at clinical decision points.

4.2 Consultation Liaison Service in the Emergency Department

Services Delivered Consultation Liaison (CL) in the emergency department is provided by specialist mental health staff. The CL team will support the parallel assessment of consumers who present to the ED requiring mental health assessment, treatment (if indicated) and linking to appropriate services for follow up and /or facilitate transfer to inpatient units if indicated. They may provide advice on clinical management and early recognition of symptoms relating to mental health to the emergency department treating team.

Operation and Diagnostic features

CL Teams operate 24 hours, 7 days per week. All people over 18 years of age with a mental health problem which may include psychosis, depression and other mood illnesses, anxiety conditions, attempted suicide and other acts of deliberate self-harm, behavioural disturbances that may be associated with substance use or severe dementia and reactions to personal crisis.

Length of Stay The ED MH journey will be completed within 4 hours for 81% of patients who access MH services via the ED.

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Intoxication, overdose and specific diagnostic pathways have been developed and will be implemented with the commissioning of a new Mental Health Short Stay Unit (MH SSU).

Patients should not be transferred to a psychiatric ward with a medical condition unless that medical condition is stable to the point that the patient could otherwise be discharged20.

For admission to a specialised Acute Inpatient Service, the following will be considered21;

> Recognised or probable psychiatric illness

Accompanying one of the following:

> Unsuccessful trail of intervention in less restrictive setting > Level of instability of illness (Imminent danger to self or others), impaired judgement

or function > Requirement of specialised procedure (ECT) or an introduction of medication which

cannot be delivered in a less restrictive setting > Requirement of complex assessment which cannot be done in less restrictive setting > Reasonable likelihood that inpatient care will result in substantial benefit to the

person.

4.3 Short Stay Unit (SSU) Services Delivered Provide acute mental health assessment and brief treatment for a short

time for stabilisation. To develop a collaborative care plan to support the return to the community or transfer to a specialised mental health inpatient unit or Immediate Care Centre.

Operation and Diagnostic features

Care is provided by a multidisciplinary team 24 hours, 7 days per week. All people over 18 years of age with a mental health problem and associated behaviour disturbances who are medically stable.

Estimated Length of Stay

Up to 72 hours.

4.4 Adult and Older Persons Acute Inpatient Units (IPU) Services Delivered Provide safe, therapeutic, engaging interventions and in a person

friendly environment. Care is provided by a multidisciplinary workforce including people with a lived experience (consumer and carer). The team will provide specialised assessment, best practice, evidence based and collaborative planning and interventions working towards when patients can transfer/discharge to a less restrictive environment. Patients will remain an inpatient until they have recovered to the point where they can be treated effectively and safely in the community by community services.

Operation and Diagnostic features Adult

These units are generally open units but can be secured for safety. Units operate 24 hours, 7 days per week. All people are at a minimum 18 years of age (some circumstances of admitting people younger than 18 may be made as per children and adolescents in Adult Services Policy Guideline) requiring a reduction in severity of symptoms and/or distress associated with recent onset or exacerbation of a mental illness. Services provided by multidisciplinary team of health professionals operating as part of a local integrated mental health system. Patients with more complex plans will be identified within 7 days and an

20 SALHN Clinical Review Committee. May 2016 21 Mental Health Directorate Model of Care New RAH Addendum: SA Health Model of Care

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integrated approach to care will be implemented to identify where the best place to receive care is within the existing stepped level of care with the MH system.

Operation and diagnostic features Older Person

Due to the complexity of illnesses and the aging process, lengths of stay may be longer in older persons IPU. OPMHS accept referrals of people who are over 65 years of age (50 years if Aboriginal or Torrens Strait Islanders) and have not been engaged with an adult MH service for a 2 year period. Acceptance of patients under 65 with a confirmed early onset neurodegenerative dementia requires approval of the Head of Unit. The psychogeriatric sub-speciality inpatient unit is generally open but can be locked for safety. Units operate 24 hours, 7 days per week. Services are provided by specialists in psychogeriatrics and other health professionals operating as part of a local integrated team with the OPMHS Community Team. People receiving care in the community and requiring transfer to the IPU will be admitted under the same psychogeriatrician.

Average Length of Stay

Adult 18 + Older Person 65 +

14 Days 30 Days

4.5 Psychiatric Intensive Care Units (PICU) Services Delivered Provides a higher level of supervision and support to people. Care is

provided by a multidisciplinary workforce, who provides safe, therapeutic, engaging interventions. The team will provide specialised assessment, collaborative planning and interventions working towards when person can transfer/discharge to a less restrictive environment. It is imperative that staff in this area have received trauma informed care training and training in de-escalation. A plan typically will include preventative strategies (what has worked in the past) and de-escalation strategies (conversation, distraction, medication, space etc.)

Operation and Diagnostic features

PICU’s are secure area within an acute mental health unit designed to provide short term safe, secure, low stimulus care for patients who mostly involuntary. Unit operates 24 hours, 7 days per week. All patients are at a minimum 18 years of age (some circumstances requiring admission of people younger than 18 may be made as per Children and Adolescents in Adult Services Policy Guideline). Only used where patients are unable to be cared for in a less restrictive setting. Patients admitted may display psychiatric symptoms complicated by severe behavioural disturbances. An emphasis is placed on management and stabilisation that will allow transfer to a less restrictive setting.

Estimated Length of Stay

7 days.

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4.6 Adult Psychiatric High Dependency Units (HDU) Services Delivered Provides a higher level of supervision and support to people. Care is

provided by a multidisciplinary workforce including people with a lived experience (consumer and carer), who provide safe, therapeutic, engaging interventions. The team will provide specialised assessment, collaborative planning and interventions working towards transfer/discharge to a less restrictive environment. A plan typically will include preventative strategies (what has worked in the past) and de-escalation strategies (conversation, distraction, medication, space etc.)

Operation and Diagnostic features

HDU’s are a secure area within acute MH Services designed to provide short term safe, secure, low stimulus care for patients who are involuntary. Unit operates 24 hours, 7 days per week. All patients are at a minimum 18 years of age (some circumstances requiring admission of people younger than 18 may be made as per Children and Adolescents in Adult Services Policy Guideline). Verbal aggression from patients may be able to be managed in the HDU environment however patients who have a significant risk of, or who demonstrate, actual physical aggression cannot be admitted to the Adult MH HDU due to limited response time from a code black team over a 24 hour period.

Estimated Length of Stay

7 days.

4.7 Older Persons High Dependency Unit (HDU) Services Delivered Provides a higher level of supervision and support to people. Care is

provided by a multidisciplinary workforce who provides safe, therapeutic, engaging interventions. The team will provide specialised assessment, collaborative planning and interventions working towards when person can transfer/discharge to a less restrictive environment. It is imperative that staff in this area have received trauma informed care training and training in de-escalation. A plan typically will include preventative strategies (what has worked in the past) and de-escalation strategies (conversation, distraction, medication, space etc.)

Operation and Diagnostic features

HDUs are a secure area within a Psychogeriatric mental health unit designed to provide safe, secure, low stimulus care for patients who are mostly involuntary. Unit operates 24 hours, 7 days per week. All patients are at a minimum 65 years of age (some circumstances of admitting people younger than 65 may be made in consultation with Older Persons Head of Unit). Patients are unable to be cared for in a less restrictive setting. Patients admitted can display psychiatric symptoms complicated by severe behavioural disturbances. The emphasis is on management and stabilisation of the distress/disturbances so they may be transferred to a less restrictive setting. Additionally, patients with severe and complex behaviours and psychosocial symptoms of dementia (BPSD) who cannot be managed in hospital based or mainstream residential aged care facilities are admitted for the purpose of a specialised multidisciplinary assessment and management plan.

Estimated Length of Stay

15 days (42 Days if BPSD).

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5. Contemporary Evidence Based Practice and Approaches:

5.1 Trauma-Informed Approach It is a mandatory requirement that all health service staff adopt a universal precautions approach to trauma-informed care for mental health presentations. It is necessary for everyone to be treated with respect, given choice, and supported to exercise control over theirown lives. The awareness of how experience of trauma can impact on clinical interactions may help prevent the emergence of challenging behaviours. From a neurobiological perspective, trauma survivors are sensitised to stimuli that may trigger fright, fight or flight response. In order to minimise challenging behaviours, practice needs to be aimed at preventing this fear response. People presenting to Mental Health Services have high rates of past trauma. People who have experienced trauma tend to have extra sensitivities in areas such as control, proximity and touch, confinement, new people and environments, and trust22.

Considerations include:

> Creating a welcoming environment > Meeting people and conferring respect > Providing options at the outset avoiding the feeling of being trapped or

confined > Minimising unnecessary and potentially aversive stimuli > Asking permission before touching > Creating a culture of collaboration within the team and with the person > Having a team approach with colleagues prepared to step in and take over

when interaction with the consumer is no longer therapeutic > Ensuring that the team has working knowledge of the person’s Personal

Prevention Plan (PPP), if one is in place.

Least restrictive practices, as supported by the MHA 2009, form an essential foundation to a trauma-informed approach and have been accepted internationally and nationally as best practice23.

5.2 Minimise Restraint and Seclusion Use of restraint and seclusion is not a therapeutic intervention; but a last resort to maintain safety for the person, staff or others.24 The focus for practice is on early intervention measures to prevent restraint and seclusion and to promote the principle of least restrictive practice.

The use of Safety Plans is a compassionate and engaging tool which supports the core principles of mental health care. The use of the plan promotes collaboration and gives the patient a voice in their care. Restraint/seclusion review pathways should be both immediate and at an individual unit level designed to minimise the use of restraint and to support staff to consider alternative strategies as well as legislative requirements. 22 SA Health Restraint and Seclusion in Mental Health Services Policy Guideline 2015 -2018 23 Queensland Mental Health commission. Options for reform Moving Towards a more Recovery-Orientated, least restrictive approach in acute mental health wards including locked wards December 2014 24 SA Health Restraint and Seclusion in Mental Health Services Policy Guideline 2015 -2018

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5.3 Connecting with People Connecting with People is evidence-based training in suicide and self-harm mitigation and emotional resilience. Tools used in the Connecting with People framework enable clinicians to:

> Interact in a respectful manner and > Be responsive, compassionate and develop engagement-based interventions.

At the heart of the Connecting with People approach is a paradigm shift in thinking about suicide; from risk assessment to comprehensive safety planning and suicide mitigation. People can gain knowledge and controls over suicidal thoughts and impulses. This benefits not only the person at risk of suicide; it also assists professionals to accept the limitations of a paternalistic approach and instead work to increase the person’s own resilience and resourcefulness25.

5.4 Therapeutic Interventions Some of the interventions that may be offered by a range of disciplines within the team include:

> Pharmacological interventions and medication review > Electroconvulsive Therapy (ECT) > Psychoeducation > Sensory Modulation > Behavioural Activation > Group therapy – structured and graded activities > Mindfulness - Individual and Group therapy > Cognitive Behavioural Therapy (CBT) > Acceptance and Commitment Therapy (ACT) > Supportive counselling > Dialectal Behavioural Therapy/ Strategies (DBT) > Peer support.

5.5 Solution Focussed Approach Solution-focused practice has its roots in the therapeutic approach devised by Insoo Kim Berg and Steve de Shazer in Milwaukee, USA.26 The approach values simplicity in philosophy and language and aims to discover ‘what works’ in a given situation, simply and practically. The focus of discussion is on solutions (not problems); the future (not the past) and on what’s going well (rather than what’s gone wrong). The approach works from a strength perspective and fits with a compassionate, person centred approach where patients come up with their own solutions for their own future.

5.6 Hearing Voices Approach The Maastricht approach to hearing voices is a framework that applies trauma formed practice and recovery principles towards individual making sense of their experience.

25 Government of South Australian. South Australian Suicide Prevention Plan 2017-2021 26 Hosany Z, Wellman N, Lowe T, The integration of solution-focused brief therapy principles in nursing: a literature review Journal of Psychiatric and Mental Health Nursing, 2007, 14, 688–695

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The approach values the professional and lived experience expertise as an equal value in working through voice hearing. The biographical approach supports the reframing of a distressing experience into a more hopeful understanding of a patient’s journey27.

5.7 Accredited Assistance Dogs and Animal Assisted Activity A dog used as a guide dog, trained hearing-assistance dog, or a dog trained to assist a person to alleviate the effect of a disability may be used in the hospital setting. Animal assisted therapy is permitted in patient areas with approval of the Infection Control Service and medical team.28 An animal-assisted activity generally refers to casual activities of the ‘meet and greet’ kind. It can involve animals and handlers visiting patients and their families in common areas, and is delivered by specially trained volunteers or professionals. Animal assisted therapy is a structured mode of tailored individual therapy that is run under professional supervision, with animals trained for the role. Goals may include improving social interaction or reducing anxiety.29

5.8 Motivational Interviewing This approach utilises the principles and practices of person centred counselling to encourage a person to move through the stages of change and to make personal choices along the way.

5.9 Potential Future Innovations:

5.9.1 Safewards: Safewards is a model that was developed in the United Kingdom by Professor Len Bowers and colleagues. It specifically examines events known in the model as ‘conflict’ (events that threaten staff and patient safety, such as self-harm, suicide, aggression, absconding) and ‘containment’ (things staff do to prevent or reduce harm to staff and patients, such as increased observation, use of extra medication, use of restrictive interventions).30 The Safewards model is derived from three main sources:

> an extensive literature review examining evidence related to conflict and containment within inpatient settings

> the research program led by Professor Len Bowers conducted over many years and specifically examining conflict and containment

> ‘reasoned thinking and integrative gestalt’31. The evaluation of the Safewards in the Victorian trial has found that Safewards can contribute to enhancing the culture and atmosphere in their mental health services. 27 Ball, M., Fort, A., Waegeli, A., Hearing Voices a common human experience: Introducing the journey from emerging distress to personal recovery in a public mental health system. Retrieved from Australian College of Mental Health Nurses September. 2017, 28 SALHN procedure Animals in the hospital 2017-2020 29 SALHN procedure Animals in the hospital 2017-2020 30 Bowers L, Alexander J, Bilgin H, Botha M et al. Safewards: the emperical basis of the model and a critical appraisal .Journal of Psychiartic and Mental Health Nursing 2014, p 354. 31 Bowers L et al P 355

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Staff and consumers reported that Safewards reduced conflict and improved communication. Theer is also evidence that Safewards can also impact on the reduction of the use of restrictive interventions.

5.9.2 Accredited Exercise Physiologists The role of an Accredited Exercise Physiologists (AEP) is to provide advice and support services to assist clients with the management of their medical condition/s. To guide treatment of specific conditions, AEPs follow evidence-based practice around assessment, developing individual exercise plans and developing/running appropriate groups. AEPs specialise in graded exercise therapy and lifestyle interventions for persons with, or at risk of developing, chronic/complex medical conditions.32 Therefore they have a good understanding of the complex health needs of those who access Acute MH services.

6. Multidisciplinary Workforce Safe care is provided by a multidisciplinary workforce, including Consultant Psychiatrists, Consultants in the sub-speciality of Psychogeriatric Medicine, Medical Officers, Nurses, Occupational Therapists, Social Workers, Clinical Psychologists, Neuro Psychologists, Lived Experience Workers (Consumers and Carers) and Activity Supervisors. Clinical staff will be registered with the appropriate professional body or accredited as per their professional organisation. Most staff will have a shared set of MH specific skills in clinical assessment (incorporating risk) and care planning, however the delivery of particular interventions may require discipline-specific expertise and training. To maintain the core principles of care as outlined in our model at a minimum staff need to be:

> Trained in cultural awareness and cultural competence > Trained in Trauma-Informed Care and other interventions which support

compassionate, engagement-based interventions > Have appropriate skills, knowledge and attitudes to provide safe and effective care,

and this needs to be supported by recruitment, professional development, clinical supervision and performance development and review (with reference to relevant core competencies)

> Meet the National Practice Standards 2013 for the Mental Health Workforce33.

32 Ledeman O, Grainger K, Stanton R, Douglas A et al Consensus statement on the role of Accredited Exercise Physiologists within the treatment of mental disorders: A guide for mental health professionals Australas psychiatry 2016 Aug 24 (4) 347-351 33 National Mental Strategy: The National Practice Standards for the Mental Health Workforce 2013

“Peer Workers (known by a number of titles including Peer Specialist, Consumer Consultant, Lived Experience Practitioner) serve a number of vital roles in supporting consumers through their experiences in acute mental health settings and onward into recovery. Aside from running groups and facilitating daily activities, Peer Workers can connect with consumers on a shared level, disclosing lived experiences of mental illness and recovery (as relevant and prudent) that help people to better comprehend their mental health challenges and journeys, and importantly, promote hope for mental health recovery”. Suze Hutchison, Consumer Consultant SALHN Mental Health. October 2017

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7. Efficiency and Effectiveness

7.1 Clinical Governance Within SALHN Acute MH Services there are Heads of Unit who are responsible for clinical care, however, clinical governance is a core activity for every staff member. Time and attention will be given to strong leadership development, communication, team work, culture change in addition to quality improvement activities such as clinical audit, critical incident reporting and complaint management. While people will encounter health care in many ways, the focus will remain on the person’s health and journey through the system.

7.2 Localised Bed Management. Bed management is localised to SALHN MH, and beds are allocated to consumers in a safe, effective and efficient manner. The Bed Allocation System (BAS) is used to provide transparency regarding MH demand from ED and community and capacity across all SALHN adult inpatient sites.

Allocation of inpatient beds for individuals over 65 years old is coordinated through OPMHS. While the majority of the admissions are from within the SALHN catchment area they do facilitate some admissions from other Local Health Networks (LHN’s). Patients from rural and remote areas are admitted according to the geographical catchment area allocated to SALHN OPMHS.

7.3 Electronic Journey Boards (EJB) The Electronic Journey Boards assist with:

> Making the patient journey visible to the whole team every day > Communication between all members of a healthcare team to progress the patient’s

journey through the unit > Planning ahead to manage patient flow.

The benefits are:

> Patient’s care is coordinated and discharge occurs in a timely manner > Data automatically populating EJB when a patient is admitted or transferred into

a ward via the Bed Allocation System (BAS), therefore reducing the risk of transcribing errors thus greatly improving data integrity.

> Improved clarity and legibility within the EJB. > Reduces duplication of information and resultant errors as used for all handover

tasks > Automatically colour coded estimated date of discharge (EDD) > Easy recognition of pending and actual referrals to community services.

7.4 Outcome measurement A standard suite of appropriate evidence-based tools, standardised outcome measures, self-reporting documents, qualitative tools and assessment of need measures will be administered within the Acute MH Services. These outcome measures will be used in the development of appropriate individual treatment plans. Outcome measures are mandated for mental health services and are undertaken according to national protocol. Outcomes are an integral part of routine clinical practice.34

34 Australian Mental Health Outcomes and Classification Network (AMHOCN)

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7.5 Key Performance Indicators Reviews and evaluations of clinical practice and outcomes will be embedded in service delivery. These will be linked to evidence-based clinical practice, safety and quality along with performance indicators based on national and state requirements.

Other indicators to be monitored include:

> Average Length of Stay as indicated in the round table relative stay index > Length of Stay greater than 35 days in acute IPU > 7 day follow up from acute IPU > Admission and discharge times > Readmission rates > ED wait times > Complaints and feedback > Sentinel and adverse events > Restraint events.

7.6 Discharge planning Discharge planning is a formal process undertaken in partnership that leads to the development of an ongoing, individualised plan of care and support which meets the patients assessed needs patient on leaving hospital. The process addresses the functional, social, cultural, therapeutic and educational interventions necessary to safeguard and enhance that person’s health and wellbeing in the community.

For those who have presented or were admitted with suicidal ideation or intent an updated individualised Safety Plan will be developed which will be made available to the patient, carer, family and other health professionals as agreed by the patients. The outcome is continuity of care which provides information to everyone.

Discharge planning involves the patient, family, the treatment team, and other service providers. It is required when a patient leaves any SALHN Acute MH facility.

I want to be involved in discharge planning; being involved invites me to think about what I need to think about when I am home. It provides me choice and control.

Person with a lived experience, Outer South Consumer and Carer Group, October 2017

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Please share the information on who is providing the service once discharge – as early as possible, and carers need to be involved in the planning.

Carer, November 2017