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A presentation byErnie Sorgini and Michael BailieMental Health, SAAS and SAPOLDeveloping Seamless Communication with a Cost Effective ApproachWestern Assessment and Crisis Intervention Service (WACIS)

CPI ProjectCentral Northern Adelaide Health Service

*Team MembersErnie Sorgini Team Leader Western ACIS - CPI Project CoordinatorMichael Bailie Senior Social Worker Western ACIS - CPI Project Coordinator Oleh Cybulka Chief Inspector Legislation & Policy MH Liaison David ODonovan Chief Inspector Port Adelaide LSAPaul Lemmer South Australian Ambulance ServiceHelen Gregor Clinical Nurse - Mental Health Services - TQEH Emergency Dept.Imelda Cairney Mental Health Nurse - Mental Health Services - TQEHJohn Antonio - Team Leader Southern ACIS Sylvia Ebert - Team LeaderMental Health Triage Service Amanda Porter MIFSA (Mental Illness Fellowship of SA)plus ConsumerFiona Johnson - MIFSA (Mental Illness Fellowship of SA)Philip Galley - Mental Health UnitChristopher McCaskill CSC TQEH EDAnne Barbara Carer Consultant Cramond Clinic plus CarerTim Gore CPI Team Support Glenside HospitalMary Anargyros Well Ways programPeter McEntee S A Ambulance ServiceWe would also like to thank our Executive, Ms Dianne Norris and Ms Michelle Hilton for supporting this CPI Project and for seeing the benefits.

*Our Mission StatementThat in 6 months time if a mental health patient (or potential mental health patient) has had a crisis visit by SAPOL / SAAS, the Mental Health Triage / Mental Health Services should be informed within 24 hours.The defined cohort of patients:- will be aged between 18-65 years; may or may not be current clients of the Mental Health Services and will reside within the western metropolitan area of Adelaide within the Western Assessment and Crisis Intervention Service area boundaries.The time frame for completion is expected to be 30/9/2009.The project is to be consistent with organisation and department strategic aims and culture.

*What is the Problem? SAPOL/SAAS usually do not contact the MHT 131465 Crisis Line before or after visiting a Western (potential or known) mental health consumer

Consumers complaining about Triage response times.

Emergency Services complaining about triage response.

As a direct result of the above - SAPOL and SAAS will often attend to a call (or convey a client to EDs) with no contact having been made with the Mental Health Services. SAPOL/SAAS attending MH presentations where MHS should be in attendance.

That there is ineffective communication between SAPOL / SAAS & MHS. This impacts directly the on client (& others). Poor communication effects client safety and the management of risk in the community. Why?.... Key reported aspects by SAAS/SAPOL are : - triaging of SAPOL / SAAS calls takes too long by MHT or - that they are kept on hold for too long prior to speaking to an operator and so hang up. They wont call 131365 (MHTS) as stats show in the next slide

NB - There currently exists a Memorandum of Understanding (MOU) Implementation Guidelines for Mental Health between SAPOL, SAAS, RFDS & MHS (2006)

*SAPOL attendances and Combined ACIS / SAPOL attendances (via MHTS) Information sourced from SAPOL & WACIS figures 2009

Chart1

1349

1920

228300

9330

Hospital Emergency Departments

Number of ED Presentations

SAAS / SAPOL - Western Area Mental Health Only Conveyances to Emergency Departments Jul 08 - Mar 09

Chart2

4141

692

2366

ACIS with SAPOL (Y)

SAPOL (Blue)

Attendances to MH Clients

Sheet1

SAASSAPOL

RAH1349

FMC1920

QEH228300

*OTHERS9330

ACIS with SAPOL (Y)SAPOL (Blue)

Sep-Dec 084141

Dec-Mar 09692

Mar-Jun 092366

Sheet2

Sheet3

*Reduce time spent for SAPOL officers at hospitals due to attendances that have been addressed by ERT attendance. Reduce SAPOL / SAAS repeat home visit attendances. Improve MHS attendance to acute settingsEasier access for SAPOL to contact MHTS or MHS as needed. Improved feedback to MHS from SAPOL/ SAAS of client contact. Improve statistics gathering due to contacts being registered on CBIS.The identification of barriers to communication with MHS by SAPOL / SAAS. Improve feedback communication by Emergency Services to Mental Health after Emergency Services have left the scene.

Benefits in rectifying the Problem

* SAAS & SAPOL Western (Port Adelaide area sample) Area Mental Health Clients Only -Conveyances to E.D.sRAH - 158 9 167QEH - 294 300 594FMC - 226 N/A(Only local LSA) OTHER - 94 30 124

TOTAL:- 772 339 111153.5% of total # went to QEH.* Others = WCH, LMHS, RGH etc Information sourced from SAAS & SAPOL 2009

Chart1

1589

2260

294300

9430

SAAS

SAPOL

Hospital Emergency Departments

Number of ED Presentations

Apr 08 - Mar 09

Sheet1

SAASSAPOL

RAH1589

FMC2260

QEH294300

*OTHER9430

SAASSAPOL

RAH1349

QEH228272

OTHERS9328

Sheet2

Sheet3

*Total costs of bringing 594 MH patients to the ED TQEH only..Transport Fees = $334,422.00 TQEH ED Fees= $481,734.00 =$816,156.00(Costs for all 1,111 Western MH clients approx = $1.5 million)

Remember (ACIS ERT involvement included above was only 3.5%= 36 clients for April 08 Mar 09)

*Cost Savings AimsReduce:MH patient transportation by SAPOL / SAAS to hospital Emergency DepartmentsMH client ED presentations involving ERTOn hold and triage referral time when ringing MHTCost (e.g. stress & trauma) to consumer and carerIncrease:Referrals to MHTS (131465) by SAPOL / SAAS and others.ERT participation which may then reduce the need for SAPOL and/or SAAS involvementSAPOL awareness/education of MH servicesCapacity for wellness to consumer and carer

*Types of calls received by MHTS .Emergency Triage = ~15% of total calls received.Information sourced from CBIS Report 2009

Chart3

84231127

83737108

183133153

183528712

74029168

54233146

64427158

44630155

547221610

44725159

445221613

351201412

55022158

549221410

452181412

454171411

45022159

45320149

44725159

64823158

45717148

357161212

Assessment

Care & Treatment

Education

Emergency Triage

Other

Sheet1

WACIS ERT VISITS 2008 - 2009

JUL 08AUG 08SEP 08OCT 08NOV 08DEC 08JAN 09FEB 09MAR 09APR 09MAY 09JUN 09

ERT Emergency Assessments91268411553478

ERT Clients Taken to ED464323231251

ERT - SAPOL Involvement253113230130

Sheet1

0

0

0

0

0

0

0

0

0

0

0

0

ERT Emergency Assessments

ERT Emergency Assessments

Sheet2

0

0

0

0

0

0

0

0

0

0

0

0

ERT Clients Taken to ED

ERT Clients Taken to ED

Sheet3

0

0

0

0

0

0

0

0

0

0

0

0

ERT - SAPOL Involvement

ERT Emergency AssessmentsERT - Taken to EDERT - SAPOL involvement

Jul-08942

Aug-081265

Sep-08643

Oct-08831

Nov-08421

Dec-081133

Jan-09522

Feb-09533

Mar-09310

Apr-09421

May-09753

Jun-09810

000

000

000

000

000

000

000

000

000

000

000

000

ERT Emergency Assessments

ERT - Taken to ED

ERT - SAPOL involvement

Number of ERT Visits

AssessmentCare & TreatmentEducationEmergency TriageOther

Aug-0784231127100

Sep-0783737108100

Oct-07183133153100

Nov-07183528712100

Dec-0774029168100

Jan-0854233146100

Feb-0864427158100

Mar-0844630155100

Apr-08547221610100

May-0844725159100

Jun-08445221613100

Jul-08351201412100

Aug-0855022158100

Sep-08549221410100

Oct-08452181412100

Nov-08454171411100

Dec-0845022159100

Jan-0945320149100

Feb-0944725159100

Mar-0964823158100

Apr-0945717148100

May-09357161212100

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

00000

Assessment

Care & Treatment

Education

Emergency Triage

Other

*SAAS Issues Other GPs etc Communication Problems MH Triage IssuesAbandoned calls at MHTMHS Response time too longMHT tell cl to go to TQEH not call CRTMHT calling SAAS/SAPOL without tasking MHS teamsACIS availability Takes too long to give info to MHTSlow response time from SAAS from SAPOL / MHS.Timeliness of responseACIS receiving minimal ERT requestsPurpose of MOUsPolice PrisonersBenchmarks 60 min MOU not working with MHTMHS IssuesSAAS/SAPOL being held up at site while MHS interview ED Issues Clients under arrest SAPOL should remain?SAPOL have limited knowledge & should not be expected to get involved in protracted mgt.ACIS Response timeInfo accessCalled in case ofBed availability Causes PrioritisingSAPOL/SAAS to contact ED prior to arrival.Easier & quicker to go straight to EDJuvenilesComorbidityOHS&W TrainingMHS.SAPOL policy knowledge will provide marketing re MHT etcSent out to jobs blindWhat is SAPOL role in relation to Mental Health? ACIS mgt of Detn Orders expect police will act in every caseAssess over phone prior to our arrivalForensic Lack of meds & knowledge.SAAS delays due to medical priorities Police then have to transport.Job Stacking-PrioritisingJNH/RAH arrangements allegedly made when patrols arrive nothing organised.Police Forensic MH no access to this info.Educate to limit ED presentationsDispute Resolution re MOUAgency staff in ED unfamiliar with MOUIssue of immediate risk for SAPOL attendance.Why delay to await services to scene when MOU provides for 30 min turnaround? SAPOL IssuesPatrols have no phones to relay infotoo hardMHS info avail for SAPOL?Cause and Effect DiagramResponse/referral times too long

*Pareto Chart80%* 2nd survey shows Lack of available clinical staff, leading to a slow response time as being paramount according to the majority of respondents.

Chart1

120.12

110.23

110.34

110.45

80.53

80.61

60.67

60.73

40.77

30.8

30.83

30.86

30.89

20.91

20.93

20.95

10.96

10.97

10.98

10.99

11

&A

Page &P

Number of Votes

Accumulative %age

Sheet1

Voting ItemNumber of Votes%ageAccumulative %age

* Slow response time from MHT1212%12%

Poor Knowledge of MHS1111%23%

ACIS availability hours of operation1111%34%

MHT to advise of Risk to client, self, others1111%45%

SAAS/SAPOL held up on-site88%53%

Lack of availability of frontline therapeutic response88%61%

SAPOL roles and knowledge of MHS66%67%

No contact with NGO's66%73%

* Identify problems over the phone prior to arrival44%77%

No ACIS involvement33%80%

Forensic issues / legality33%83%

Carers want help from MHS not SAPOL33%86%

Police don't understand MH issues33%89%

No overnight MH nurse22%91%

Lack of availability of medical staff (volume pt's in ED)22%93%

Mental illness seen as health not SAPOL22%95%

Knowledge11%96%

Narrow pathway11%97%

Difficult to access guards11%98%

Time11%99%

Pathways11%100%

Total Votes71

Sheet2

Sheet3

*PDSA 1

Plan - To increase frontline therapeutic intervention at MHTS with SAAS to reduce attendances at ED with MHTS being advised within 24 hours Co-locate MHTS clinician onsite at SAAS. SAAS have set guidelines for referring calls to MHTS. DO - Started 24/7/2009. One MH Clinician who sits at 000 Facility with the SAAS call taker to take Mental Health Referrals. STUDY the dataTest data to date shows improvement. Data to date (approx mid point) shows an improvement on over 50% (89 calls taken 49 ambulances cancelled). Continue for a Month (till end of 0809)Can this be implemented on a larger scale - Yes?ACTEnd of Month (0809) results shows 115 MHS calls to 000. Recommend intervention to be ongoing.

*PDSA 2Plan - To have obtained a new dedicated Hotline number for SAPOL/SAAS to call and bypass the 131465 starting 1/10/2009Do New mobile phone number has been provided (as above) to MHTS for use An Intake form (Hotline Intake Referral Form H.I.R.F.1) for MHTS clinicians has been developed due for trial 1/10/2009 in consultation with SAPOL/SAAS for 3/12 A one page Fax form for SAPOL to fax directly to MHTS has been developed in consultation with SAAS/SAPOL and approved-due for trial 1/10/2009 for 3/12VPN - Wireless laptop link approved awaiting delivery of equipment for trial 1/10/2009 for WACIS team (ERT) Study Results pending 3/12 trial from Oct 2009

ACT Beginning 1st Oct 2009

*CPI SA08 OUTCOMES (up to and including August) 2009 That the client / carer will receive appropriate MH Services intervention rather than mainly SAPOL/SAAS. Reduction of SAAS attendances to MH clients for August 2009:Out of 115 calls 59 Ambulances were cancelled or not required for MH clientsThis is a 51.3% Reduction of SAAS Attendances to MHS clients and possible ED admissionsCost Saving for the Trial is approx. $47,850.00 in one month of trialCost efficiencies leading to smart use of this money for other areas in MHSSeamless reporting structure Redesigning and improving communication between SAPOL, SAAS and MHSReducing SAPOL/SAAS transportation to ED with MH intervention within 24 hoursDecrease SAAS/SAPOL involvement and increasing MH involvement within 24 hoursIncreasing opportunity for MHS Early Intervention / Treatment Conclusion.. There is a direct correlation between the poor communication from SAPOL/SAAS/MHTS resulting in costly service inefficiencies that directly impacts on the consumer. This CPI recommends that the current trials be implemented Statewide and should be evaluated within the next six months.

*Progressive Final Pilot Project Report from August 2009 to March 2010Graph following shows the final statistics that have resulted from the undertaken Project..

*Final Report Summary of Pilot Project CPISA08 2009-2010Statistics - MH Clinician in SAAS Emergency Operations Centre

Month No of Calls No of Ambulances % Taken NOT required August 2009 115 59 51.3%September 200998 45 45.9%October 2009 602948.3%November 2009643148.4%December 2009623556.5%January 2010794848.1%February 2010 723954.2%March 2010492653.1% 59931252.1%

*Emergency Operations Centre (SAAS).The following bar Graph shows. the number of calls taken by a mental health clinician at the Emergency Operations Centre (NB stats gathered were taken during ONE - 8 hour shift only per day) versus the number of ambulances tasked from the Emergency Operations Centre (SAAS)Then, shows the percentages of Ambulances diverted by MHTS clinicians at the 000 call centre.

*Statistics - MH Clinician in SAAS Emergency Operations Centre cont

Chart1

1155951.3

984545.9

602948.3

643148.4

623556.5

794848.1

723954.2

492653.1

No. of calls taken

Amb. Not Required

Percent

Sheet1

Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10Feb-10Mar-10

No. of calls taken11598606462797249

Amb. Not Required5945293135483926

Percent51.345.948.348.456.548.154.253.1

Sheet1

000

000

000

000

000

000

000

000

No. of calls taken

Amb. Not Required

Percent

Sheet2

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*Interpretation The graph show a tapering trend downwards in demand of callers using the service with having a Mental Health clinician attached to the SAAS-EOC. Why is this happening? 000 Calls made to the EOC have been identified to be known clients and /or frequent callers over-utilising this emergency service rather than calling the 131465 MHTS

*Statistics and Cost Savings from this Project for SAAS/MHTSResults - In saving 312 ambulances from attending a scene, using the current costing model of an average transport cost at $811 savings made from August 2009 to end of March 2010 equates to $253,032

Assumption larger cost savings could have been made if the SAAS 000 criteria was expanded and referred to MHTS clinicians to further triage these calls.

Moreover there could also be more of a coordinated partnership model to be further developed between SAAS and MHTS. This should improve costs reductions and result in a more focussed clinical intervention program to identify MH clients needs sooner.

*SAPOL Referral(s) Outcomes- ERT and Non-Urgent -The following slide/stats shows the period of Dec 09 March 2010.The number of evidenced referrals from SAPOL to MHTS was under estimate as was ERT taskings/referralsThat Western ACIS was only involved in only 3.5% of all presentations see slide 8No figures are available for costings from SAPOL regarding transport to and from EDs (with ERTs and non Urgent presentations).Referrals to MHTS Hotline were not used. Stats available refer to faxed referrals for non-urgent clientsFurthermore It appears that SAPOL continue to bypass MHTS referrals and transport MH clients directly to ED TQEH etc.

*Non-Urgent Referrals from SAPOL to MHTS using new referral processCommencing 1st Dec 2009Dec 7 referrals (6 referred to Community MHS 1 No Follow Up Required)Jan 2 referrals (both referred to Community MHS)Feb 7 referrals (6 referred to Community MHS 1 No Follow Up Required)Mar 2 referrals ( 1 referred to Community MHS 1 No Follow Up Required)Note: Between 15.12.09 08.02.10 = 68 & between 9.02.10 6.04.10 = 44 clients were taken directly to TQEH ED by SAPOL

*Emergency Response Team Mental Health (ERT)From Aug 2009 Mar 2010 there were 42 ERT attendances out of which 15 ERT clients were taken to TQEH-ED.From these figures it is indicative that the service provided by ERT is under utilised by Emergency Services a possible reason for the very low referral numbers are that the calls made to the direct 24 hour mobile phone hotline at MHTS (as per pilot project initiative) are possibly due to the lack of knowledge about the improved referral communication pathwaysCurrent practices of taking mental health clients to the ED directly still continue. This practice may be viewed as the quickest way for emergency services to expedite the conveyance of clients to the ED.A further hypothesis for the low referral to MHTS may also include certain historical work practices that are culturally ingrained within the emergency services organisation(s)That there could be a lack of awareness of the seamless and improved direct referral pathways to MHTS for referring emergency services This is an area which will need further education and development between SA Emergency Services and the MHTS in the future.

*Recommendations SuggestedWith the Review of the Memorandum of Understanding between MH services, Police and Ambulance currently in progress in 2010 the findings of this project provide essential information for future service planning. The evidence in this CPI project provides and opportunity here to incorporate this model statewide within the current MOU review.More educational sessions are needed to update Police and Ambulance about utilising / accessing Mental Health Triage Service (MHTS) more efficiently.Management from all services need to undertake and incorporate the reforms suggested in this CPI project as statistics (and cost savings) can be improved overall. This will better provide a more comprehensive and responsive service to our MH consumers within South Australia.

*ENDInformation contained in this CPI Project presentation was researched, compiled and collated by Ernie Sorgini and Michael Bailie CNAHS - Western ACIS 2009-2010

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