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CONTENTS
1
MENTAL HEALTH STEPPED CARE MODEL South Eastern Melbourne Primary Health
Network (SEMPHN)
December 2016
CONTENTS
2
TABLE OF CONTENTS 1. Introduction ........................................................................................................................................ 5
1.1. What is the stepped care model? .................................................................................................... 5
1.2. Why has the stepped care model been developed? ..................................................................... 5
1.3. What is the scope of the stepped care model? ............................................................................ 6
1.4. How will it be used? .......................................................................................................................... 6
1.5. How was it developed? ...................................................................................................................... 7
2. The policy environment .................................................................................................................... 8
2.1. PHN commissioning ............................................................................................................................ 8
2.2. Mental health policy .......................................................................................................................... 8
2.3. Broader policy links ......................................................................................................................... 10
3. Regional profile ................................................................................................................................ 11
4. The stepped care model ................................................................................................................. 13
4.1. Design principles .............................................................................................................................. 13
4.2. Model overview ................................................................................................................................ 15
4.3. Service access and coordination ................................................................................................... 18
5. Operationalising the model ............................................................................................................ 20
5.1. Governance ....................................................................................................................................... 20
5.2. Implementation approach .............................................................................................................. 20
5.3. Program transition ........................................................................................................................... 21
6. Telling the story ............................................................................................................................... 22
6.1. Introduction ...................................................................................................................................... 22
6.2. Measuring outcomes ........................................................................................................................ 22
6.3. Reporting on performance ............................................................................................................. 22
7. Service elements .............................................................................................................................. 25
Appendix A References
FIGURES:
Figure 1 – Stepped care model .............................................................................. 16
Figure 2 – Governance arrangements ....................................................................... 20
Figure 3 – Implementation of the Stepped care model .................................................. 21
TABLES:
Table 1 – Core design principles ............................................................................ 13
Table 2 – Stepped care model outcomes framework ..................................................... 23
CONTENTS
3
GLOSSARY
Term Meaning
ATAPS Access to Allied Psychological Services
CALD Culturally and Linguistically Diverse
Consumer Consumers are those who access or who could potentially access mental
health services.
Gatekeeper A person who holds an influential position in an organisation or community
who coordinates the actions of others. This could be an informal local
opinion leader or a specially designated person, such as a primary-care
provider, who coordinates patient care and provides referrals to specialists,
and other medical services.
LGBTI Lesbian, Gay, Bisexual, Transgender and Intersex
LHN Local Hospital Network
MBS Medicare Benefits Scheme
MHNIP Mental Health Nurse Incentive Program
Natural supports People who have a support role for someone living with a mental health
difficulty. They may be a family member, friend, carer or have another
close relationship with the person.
PBS Pharmaceutical Benefits Schedule
PHN Primary Health Network
Self-harm Deliberate damage of body tissue, often in response to psychosocial
distress, without the intent to die. Sometimes called self-injury, self-
inflicted injuries, or non-suicidal self-harm/injury.
SEMPHN South Eastern Melbourne Primary Health Network
SEWB Social and Emotional Wellbeing
Severe and complex
mental illness
Like other health conditions, mental illness impacts at different levels of
severity, ranging from mild to severe. Clinically, severity is judged
according to the type of disorder the person has (diagnosis), the intensity of
the symptoms they are experiencing, the length of time they have
experienced those symptoms (duration) and the degree of disablement that
is caused to social, personal, family and occupational functioning
(disability). Some diagnoses, particularly schizophrenia and other
psychoses, are usually assigned to the severe category automatically, but all
disorders can have severe impact on some people.
An estimated 3.1% of the population have severe disorders, equivalent to
690,000 people. About one third of the severe group have a psychotic
illness, primarily schizophrenia or bipolar disorder. The largest group
(approximately 40%) is made of people with severely disabling forms of
anxiety disorders and depression.
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For the purpose of this document, severe and complex mental illness refers
to individuals with clinically severe mental illness as well as complex
multiagency needs, often both clinical and non-clinical, which may be or an
episodic or persistent nature.
Support
Treatment Clinical services received by a consumer
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1. Introduction
This document sets out a stepped care model for primary mental health services in the South
Eastern Melbourne region, intended to guide stakeholders in regional service planning and
development.
1.1. What is the stepped care model?
The stepped care model describes a continuum of key service elements that are required to
most efficiently provide needs-based support to people with (or at risk of) mental illness. It is
based on six design principles, which seek to shape a regional mental health system that is:
1. Person-centred: The model is person centred, mindful of natural supports, and recovery
orientated, and delivers a consistent experience no matter the entry point or pathway
through the system
2. Effective: The overall model and the service elements within it are supported by the
existing evidence base for approaches that work
3. Flexible: The model provides for a spectrum of service elements from least to most
intensive, in a range of modalities, times and places
4. Efficient: The model seeks to deliver access to the lowest cost service that will meet
each individual’s need
5. Timely: The model facilitates timely access to services both over the life course and
within an episode of illness
6. Coordinated: The model enables and supports coordination and integration of mental
health and other services in the region
The services that fall within the scope of the model are defined by the Australian Government’s
guidance on developing stepped care approaches in mental health (Department of Health,
2016g), as well as specific guidance relating to different service types (Department of Health,
2016a, 2016b, 2016c, 2016d, 2016e, 2016f, 2016h).
1.2. Why has the stepped care model been developed?
The stepped care model reflects SEMPHN’s intentions for strengthened primary mental health
services in the region, and provides a clear basis for future work planning, including
commissioning services.
Primary Health Networks (PHNs) have been established with the key objectives of increasing the
efficiency and effectiveness of medical services for patients, particularly those at risk of poor
health outcomes, and improving coordination of care to ensure patients receive the right care in
the right place at the right time.
A priority area for PHNs is primary mental health care. PHNs have regional responsibility for
commissioning approaches to service planning and development.
CONTENTS
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1.3. What is the scope of the stepped care model?
PHNs have been funded to undertake comprehensive regional mental health planning and
identify primary mental health service gaps within a stepped care approach, and to commission
primary clinical mental health services.
Figure 1 – The stepped care model in context
While the stepped care model is designed to intersect and provide linkages, the following areas
are out of scope for the stepped care model:
psychosocial support services for consumers and natural supports
acute secondary and tertiary mental health services
severe and persistent care packages delivered under the NDIS
services outside of the SEMPHN catchment
services funded through private health insurers.
1.4. How will it be used?
The services and programs (‘service elements’) described within the model are the building
blocks for an effective primary mental health system. The model will directly inform how
SEMPHN implements its role in collaboration with consumers, natural supports, providers and
sector stakeholders to deliver on six priority areas of focus (Department of Health, 2016g):
1. appropriately support people with or at risk of mild mental illness through development
and/or commissioning of low intensity mental health services
2. support region-specific, cross sectoral approaches for children and young people with, or at
risk of mental illness, including those with severe mental illness being managed in primary
care
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3. address service gaps in the provision of psychological therapies for people in rural areas and
other under-serviced and/or hard to reach populations
4. commission primary mental health care services for people with severe mental illness being
managed in primary care, including clinical care coordination for people with severe and
complex mental illness
5. encourage and promote a regional approach to suicide prevention
6. enhance and better integrate Aboriginal and Torres Strait Islander mental health services at
a local level.
The model also emphasises intended outcomes for consumers and for the system overall. It
provides guidance on how progress towards these can be measured.
1.5. How was it developed?
The stepped care model represents a key output to an extensive process led by SEMPHN. Sector
wide consultations with consumers, natural supports , service providers and sector stakeholders
commenced as part of needs assessment and planning activity, and culminated in a workshop in
November 2016 at which the model was ‘road tested’ with key sector representatives. A
consumer and natural supports panel was convened to provide direct input to its development,
and a ‘peer review’ panel of experts reviewed the draft model.
CONTENTS
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2. The policy environment
The stepped care model outlined in this document sits within the context of mental health
policy developments at the state and federal levels. This section outlines the policy context,
identifying the key policies which have informed the development of the stepped care model.
2.1. PHN commissioning
A key role for PHNs is to lead mental health and suicide prevention planning and integration at a
regional level in partnership with Local Hospital Networks (LHNs) and other key regional
stakeholders, consistent with the Government Response to the Review of Mental Health
Programmes and Services. All PHNs have key deliverables associated with this function in the
2017 financial year, including Mental Health and Suicide Prevention Needs Assessment (building
on initial assessments in 2016), and Mental Health Activity Workplans (Department of Health,
2016i).
Primary Health Networks are also expected to deliver Regional Mental Health and Suicide
Prevention Plans in 2017. There is a strong emphasis from government on the evidence-based
and regionally collaborative nature of these plans, and that they should be comprehensive in
that they are to address the full range of mental health services (with the apparent exception of
inpatient services). A key outcome expected of the plans is that they will also guide the efficient
commissioning and targeting of services by PHNs.
The focus of commissioning models is to be on strategically assessing needs and priorities and
shaping the local service system in response. This requires a systemic focus that extends beyond
narrow procurement of individual, siloed services.
The Commonwealth Government outlines a stepped care model as an approach with a “hierarchy
of interventions, from the least to the most intensive, matched to the individual’s needs”
(Department of Health, 2016g). The model is based on the approach outlined by the Australian
Government Response to Contributing Lives, Thriving Communities – Review of Mental Health
Programmes and Services (Department of Health, 2015). The Commonwealth Government
expects SEMPHN to commission mental health services for its catchment on the basis of the
model.
2.2. Mental health policy
Mental health policy frameworks exist at both the state and national level, influencing SEMPHN’s
work in the south-eastern Melbourne catchment. The main policy frameworks of relevance to
SEMPHN are:
the Victorian 10-Year Mental Health Plan (Department of Health and Human Services, 2015)
the Fifth National Mental Health Plan (currently in draft form under consultation).
The Victorian 10-Year Mental Health Plan was launched in 2015 and has four key focus areas:
improving the mental health and wellbeing of all Victorians
promoting mental health for all ages and stages of life
supporting Victorians with mental illness to live fulfilling lives of their choosing, with or
without symptoms of mental illness
achieving an accessible, flexible and responsive mental health service system and workforce.
CONTENTS
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Additionally, the Fifth National Mental Health Plan is currently in draft and identifies the
following seven priority areas:
integrated regional planning and service delivery
coordinated treatment and supports for people with severe and complex mental illness
suicide prevention
Aboriginal and Torres Strait Islander mental health and suicide prevention
physical health of people living with mental health issues
stigma and discrimination reduction
safety and quality in mental health care.
These plans, and a number of other policy documents (see Annotated Bibliography) identify a
number of themes for the development of a mental health system that promotes the health,
wellbeing and recovery of people with mental illness.
The primary goal of the mental health system is improved outcomes for people with mental
illness, notably reduced rates of mental illness and suicide. As well as applying to all Australians
at a population level, there are specific target groups that experience high rates of mental ill-
health which needs to be addressed, including Aboriginal and Torres Strait Islander people,
LGBTI people and people with a culturally and linguistically diverse (CALD) background.
Part of the challenge of developing an effective mental health system is care coordination, both
within the system and holistically across the dimensions of people’s experiences. This means
coordination between services to ensure appropriate referrals are made. Additionally, it requires
mental health services to work with other community and social services to support a
consumer’s mental health, including education, housing, justice and family violence services.
In addition to improving the coordination of the system, there is a focus on improving the quality
and equity of services. Services and their staff should treat consumers with respect. People
should be able to access adequate services, regardless of their financial situation or location.
Where possible, consumers should have choice and control over the services that they access.
Alongside the emphasis on improving the quality and accessibility of services, reducing the
stigma and discrimination that people with mental illness face would improve their mental
health and wellbeing. Policy frameworks at the state and federal level emphasise the
importance of increasing action and education to reduce stigma, in the community and among
the health workforce.
In addition to the directions provided at the strategic level, services providing mental health
services are subject to the National Standards for Mental Health Services (Commonwealth of
Australia, 2010). These Standards outline a number of principles for the delivery of equitable,
quality mental health care, which inform the key performance indicators for health services.
NMHS: key principles for mental health service delivery
Effectiveness
Appropriateness
Efficiency
Accessibility
Continuity
Responsiveness
Capability
Safety
Sustainability
CONTENTS
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2.3. Broader policy links
Mental health service delivery is complex, and intersects with a number of other health and
social policy areas.
The National Disability Insurance Scheme (NDIS) will have a significant impact on the provision of
mental health services in the community for consumers experiencing ‘complex and persistent’
psychosocial disability associated with mental illness (National Disability Insurance Agency,
2015). There are current concerns in the sector about the extent to which the NDIS can fully
cover the number of consumers who experience severe and complex mental illness.
In addition to mental health services, PHNs are also responsible for commissioning some drug
and alcohol treatment services. PHNs aim to reduce the harms associated with drugs and
alcohol, with a specific focus on methamphetamine use and supporting Indigenous services.
Given the high prevalence of dual diagnosis mental illness and substance misuse, it is important
to acknowledge the potential interaction of services, while noting the separation of funding and
commissioning arrangements.
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3. Regional profile
.
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4. The stepped care model
4.1. Design principles
The core principles informing the stepped care model are set out in Table 1, along with high
level outcomes that result from implementing these principles. These align to the
Commonwealth’s guidance for PHNs (Department of Health, 2016i, 2016j), and are informed by
consultations completed by SEMPHN with consumers, natural supports and service providers in
the region.
Table 1 – Core design principles
Design principle Long term outcomes from design implementation
Person-centred: The model is
person centred, mindful of
natural supports, and recovery
orientated, and delivers a
consistent experience no matter
the entry point or pathway
through the system
Consumers and those supporting them have a positive
experience when accessing support, care and treatment
Consumers experiencing social disadvantage access care on
an equitable basis
Consumers access services that are culturally safe and age-
appropriate
Consumers have choice and control over their mental health
service access as far as is reasonable
Effective: The overall model and
the service elements within it are
supported by the existing
evidence base for approaches that
work
Consumers experience improved mental health and
wellbeing outcomes
Rates of self-harm and suicide in at-risk groups are reduced
Flexible: The model provides for
a spectrum of service elements
from least to most intensive, in a
range of modalities, times and
places
Consumers access appropriate mental health care in
modalities aligned to their individual needs
Consumers access flexible services at times and places that
meet their needs
Efficient: The model seeks to
deliver access to the lowest cost
service that will meet an
individual’s need
Resources available to the system are deployed sustainably
and efficiently
Services are available consistently and equitably across the
region
Timely: The model facilitates
timely access to services both
over the life course and within an
episode of illness
Downstream costs of care decrease through earlier
intervention
Consumers access needs-appropriate mental health care in a
timely way
Coordinated: The model enables
and supports coordination and
integration of mental health and
other services in the region
Consumers with mental illness experience improvement in
cultural, physical and social outcomes
Consumers experience well-coordinated services as they
move through the stepped care model
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Service providers and clinicians experience a well-
coordinated system
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15
4.2. Model overview
A stepped care model has four core elements (Department of Health, 2016g):
1. stratification of the population into different ‘needs groups’
2. defining differentiated interventions for each group – this is necessary because not all needs
require formal intervention
3. a comprehensive ‘menu’ of evidence based services required to respond to the spectrum of
need
4. matching service types to the treatment needs of each needs group.
The stepped care model shown in Figure 2 stratifies the population into five groups, ranging
from whole of population needs for mental health promotion and prevention, through to those
with severe, persistent and complex conditions. It also clusters service types by the demographic
segment that they serve. The service groupings are:
General adult services, including services for older adults
Child and youth specific services
Services for socially disadvantaged groups, including (but not limited to), culturally and
linguistically diverse (CALD) people and new migrants, people experiencing homelessness,
and LGBTI people
Aboriginal and Torres Strait Islander services
The groupings are not mutually exclusive. Some consumers fall into all four groups, and most
service providers operate across more than one service grouping.
Within each service grouping, ‘service elements’ are described. Service elements are high-level
descriptions of the evidence-based service or programs that collectively make up the range of
interventions available to consumers within the system.
Service elements are each described in more detail within section 5, with the exception of
greyed out elements. The latter fall outside the scope of the model, but are key system
components that provide important context within the diagram. For clarification, not all of the
service elements will be funded by SEMPHN and the distribution of current funds will be directed
to support future commissioned activities in scope for the stepped care model.
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Figure 2 – Stepped care model
CONTENTS
17
What does the model mean for consumers?
What does the model mean for services?
The model depicts a system in which consumers
access a range of well-coordinated services of
varying levels of intensity, delivered in a way
that is appropriate in the context of each
individual personal circumstances.
The model depicts a system in which a range of
different service elements are efficiently
delivered at lowest level intensity appropriate to
individual needs, at the earliest possible point in
a consumer’s illness.
Case study (TBC)
Case study (TBC)
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4.3. Service access and coordination
The stepped care model described in Figure 2 focuses on articulating the range of key service
elements available to people with different needs. Effective pathways into and between services
are also a critical feature of the model overall, and will be supported through the operation of a
centralised information, intake assessment and referral service. The primary pathways into and
through the system are shown in Figure 3.
Figure 3 – Consumer pathways
The approach to service access and coordination is consistent with the key principles that
underpin the stepped care model. The information, intake assessment and referral approach will
be person-centred, adopting a no-wrong-door approach with multiple possible entry points, and
coordinated, offering efficient linkage to a range of service elements of different intensities
over a person’s recovery journey. This supports consumers to access appropriate services in a
timely and efficient way, while minimising duplicative contact.
In addition to articulating what consumers can expect from their pathway through the system, a
coordinated approach articulates the roles and responsibilities for services, including relevant
communication and information sharing channels.
Exiting from the stepped care model does not mean a ‘hard exit’ from mental health services
and supports, but rather a step down to natural supports. Exit does not preclude someone from
re-entering the stepped care model in the future if their needs change.
Table 2 sets out the key design parameters for the information, intake and referral service, and
the expected outcomes that follow from its implementation. Key design parameters are high-
level descriptions of the critical aspects of a service and guide the subsequent development of
service model or detailed specifications.
CONTENTS
19
Table 2 – Information, intake and referral: key design parameters
Key design parameters Outcomes
Information,
intake and referral
The purpose of this
service element
will be to provide a
single point of
access for
information,
linkage and referral
to services
available through
the primary mental
health care system.
Consumers, natural supports and service providers can access a single point of
information about available services either online and by telephone.
Consumers can self-refer to the intake service and be connected in a timely way
to appropriate service elements. Where service elements are not immediately
available (e.g. due to wait lists), consumers are linked to interim supports.
Consumer contact will be with appropriately skilled and qualified clinical staff
able to undertake preliminary needs assessments and determine the most
appropriate point of immediate referral. Staff also undertake risk assessments
and connect people to crisis service where there is high and imminent risk of
self-harm.
Care-coordination type service providers (including GPs) can connect consumers
to service elements that make up a person’s care plan/recovery plan through
the intake and referral service.
Consumers will be connected to care-coordination services as a priority after
assessment, where these are necessary and not already in place.
Service providers must refer consumers through the service to access SEMPHN
funded services and programs.
The service collects key data from consumers and providers on episodes of care
and outcomes consistent with the Minimum Data Set. These SEMPHN funded
services and programs (and others by negotiated agreement) will provide data
on episode commencement and closure, and on consumer outcomes.
Data collected by the intake and linkage services will be available to services
(with consumer consent) to minimise duplication and repetition.
The service complements (rather than duplicating) existing system entry points
and processes, including entry via specific services.
Consumers experience well-
coordinated services as
they move through the
stepped care model
Service providers and
clinicians experience a
well-coordinated system
Consumers access
appropriate mental health
care in modalities aligned
to their individual needs
Consumers access flexible
services at times and places
that meet their needs
Consumers and those
supporting them have a
good experience when
accessing support, care and
treatment
Resources available to the
system are deployed
sustainably and efficiently
Downstream costs of care
decrease through earlier
intervention
CONTENTS
5. Operationalising the model
5.1. Governance
The SEMPHN Board oversights the implementation of the stepped care model, and in delivering
this mandate receives advice as appropriate from the Clinical and Community Councils
established by the PHN. The SEMPHN Executive are accountable for the implementation of the
stepped care model. Specific service elements implemented under the model will be expected
to have arrangements in place to ensure appropriate levels of clinical governance, quality and
risk management.
The proposed governance arrangements are summarised in Figure 4.
Figure 4 – Governance arrangements
5.2. Implementation approach
South Eastern Melbourne PHN has been tasked with a regional leadership role in primary mental
health care, and will have overall responsibility for advocating and enabling the implementation
of the stepped care model.
This will involve SEMPHN directly commissioning and funding some services (e.g. low intensity
services, targeted psychological therapies, clinical care coordination), but also extends to
regional planning, coordination and service integration (e.g. regional suicide prevention).
While this document sets out the aspirations for the stepped care model, implementation will be
staged. An early priority will be commissioning targeted psychological therapies and clinical care
coordination services and ensuring a smooth transitioning from the Access to Allied Psychological
Services (ATAPS) and Mental Health Nurse Incentive Program (MHNIP).
CONTENTS
Figure 5 provides an overview of the implementation approach. The implementation approach
will be established in a companion document, the SEMPHN Mental Health Stepped Care
Commissioning Plan (the Commissioning Plan).
The Commissioning Plan will include what is being commissioned, when and how. Drawing on
the stepped care model, it will include high-level specifications for system elements (or groups
of system elements) being commissioned, including the purpose, general scope and service
parameters, key design features and intended outcomes, and relationship to the stepped care
model.
Implementation will be supported by extensive workforce-readiness campaign led by the PHN.
This will included targeted education for GPs, practice managers, allied health providers and
others engaged in primary mental health service delivery.
Figure 5 – Implementation of the Stepped care model
5.3. Program transition
The introduction of the stepped care model will result in some existing services and programs
moving into the model, or where programs cease, consumers will need to be transitioned to new
supports. While the stepped care model describes the intended end state, transitional
arrangements are likely to be in place for some services to ensure minimal disruption to
consumers.
Service element working groups will have responsibility for identifying transition issues and
developing strategies to maintain continuity of service, with input from clinical and consumer
advisory groups as appropriate.
CONTENTS
6. Telling the story
6.1. Introduction
A key tenet of successful implementation of the stepped care model is a commitment to
monitoring and evaluation. Monitoring and evaluation serve two key purposes:
maintaining accountability to consumers and their support networks, the community and
funders
providing data to inform ongoing implementation and future design improvements.
Gathering the right data will allow a ‘performance story’ to be told about how well the system is
operating and the extent to which it is achieving its intended outcomes.
6.2. Measuring outcomes
The outcomes framework for the stepped care model is set out in Table 3 over the page.
The stepped care model design principles articulated in section 4.1 are intended to result in the
achievement of key long term outcomes for consumers and for the system overall. Indicators are
included for each outcome that will signal change in the long-term outcomes.
However, many of these outcomes may take some time to be realised. To allow for progress to
be monitored, lead indicators are also proposed within this framework to provide an earlier
picture the trajectory of achievement. These indicators are indicated by the ▲ symbol, and are
those expected to show positive change within three years.
6.3. Reporting on performance
The outcomes framework will support SEMPHN to tell the ‘performance story’ for the region’s
primary mental health services. The key indicators that make up the framework provide insight
into different dimensions of performance, and will capture significant changes over time.
Analysing system performance enables targeted effort to improve areas of underperformance,
and provides a form of systemic accountability. The complexity of the health system, and the
socio-economic environment it is situated within, mean that there are many factors that can
lead to changes in indicators. The extent to which SEMPHN is able to directly influence indicator
results will vary.
Once specific measures are developed for each indicator, regular reports on system performance
will be published by SEMPHN to ensure system accountability to the community.
CONTENTS
Table 3 – Stepped care model outcomes framework
Long term outcomes Proposed indicators PERSO
N-C
EN
TRED
NESS
Consumers and those supporting them have a good
experience when accessing support, care and
treatment
Consumer satisfaction with primary care services ▲
Natural Supports satisfaction with primary care services ▲
Consumer satisfaction with referred services ▲
Consumers experiencing social disadvantage access
care on an equitable basis Service utilisation rates by population sub-groups
Distribution of centres of service provision ▲
Consumers access services that are culturally safe
and age-appropriate
Consumer satisfaction with primary mental health services by sub-group
Utilisation rates for sub-group targeted services ▲
Utilisation rates for interpreter services ▲
Consumers have choice and control over their mental
health service access as far as is reasonable
Distribution of services
Consumer satisfaction with care planning and coordination
EFFECTIV
EN
ESS Consumers experience improved mental health and
wellbeing outcomes
Population rates of subjective wellbeing
Population rates of psychological distress
Reported clinical outcomes from primary mental health care ▲
Rates of self-harm and suicide in at-risk groups are
reduced
Age-standardised rate of death by suicide
Emergency department presentations relating to intentional self-harm
Hospital admissions relating to intentional self-harm
FLEXIB
ILIT
Y
Consumers access to appropriate mental health care
in modalities aligned to their individual needs
Service utilisation rates by diagnosis and functional ability
Service utilisation rates by low, moderate and high intensity services ▲
Service utilisation rates by modality
Consumer satisfaction by low, moderate and high intensity services ▲
Consumers access flexible services at times and
places that meet their needs
Service utilisation after-hours ▲
Consumer self-reported difficulty accessing health services ▲
CONTENTS
EFFIC
IEN
CY
Resources available to the system are deployed
sustainably and efficiently
Rates of referral completion ▲
Rates of service episode completion ▲
Service element continuity over time
Services are available equitably across the region Ratio of key mental health professions to population
Distribution of centres of service provision
Service utilisation rates by geography ▲
TIM
ELIN
ESS
Downstream costs of care decrease through earlier
intervention
Avoidable hospital admissions related to mental health
Hospital admissions related to intentional self-harm
Avoidable emergency department presentations related to mental health ▲
Consumers access needs-appropriate mental health
care in a timely way
Consumer self-reported difficulty accessing health services ▲
Natural Supports self-reported difficulty accessing health services ▲
Waiting times to appointments with mental health professionals
Avoidable emergency department presentations related to mental health
CO
ORD
INATIO
N
Consumers with mental illness experience
improvement in cultural, physical and social
outcomes
Consumer physical health status on key markers
Consumer economic participation
Consumer social participation and personal connectedness
Consumers experience well-coordinated services as
they move through the stepped care model
Consumer satisfaction with referred services ▲
Consumer satisfaction with care coordination ▲
Population rate of mental health plans ▲
Service providers and clinicians experience a well-
coordinated system
Service satisfaction with referral and care coordination pathways ▲
▲ Indicators expected to show positive change within 3 years.
SEMPHN MENTAL HEALTH STEPPED CARE MODEL_SEMPHN WEBSITE FINAL SERVICE ELEMENTS 25
7. Service elements
This section provides a concise description of the key service elements that make up the stepped care model. At this stage of drafting this
section reflects the range of services described as in-scope within the Commonwealth’s guidelines, although these may be amended in
consultation with SEMPHN and stakeholders.
GENERAL ADULT SERVICES
Service element Service element description
Community-based suicide risk identification and prevention
The purpose of this element is to support existing community-based suicide risk identification and prevention through workforce training and education, particularly for system ‘gatekeepers’, and providing follow-up and support for adults who have self-harmed or attempted suicide.
Self-directed digital MH services The purpose of this service element is to provide online support services for adults experiencing, or at risk of, mild mental illness.
Low intensity peer-led interventions The purpose of this service element is to provide low intensity interventions for adults with, or at risk of a mild mental illness.
Clinician supported digital MH services The purpose of this service element is to provide clinician supported online mental health services for adults with moderate mental illness.
GP-led care coordination The purpose of this element is to provide clinical care coordination for adults with a mild-moderate mental illness.
Linkages to broader social supports The purpose of this service element is to link adults experiencing mild-severe into the broader social supports necessary to live a meaningful life.
Higher intensity peer-led interventions
The purpose of this service element is to provide additional support for adults experiencing a moderate-severe mental illness than is otherwise provided through GP/psychiatrist coordinated care, including the Better Access initiative.
Complex care and support coordination The purpose of this service element is to provide support for a mental health professional to provide a care coordination role for people with severe and complex mental illness, in community-based general practices, private psychiatrist services and other appropriate services.
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CHILDREN AND YOUTH SERVICES
Service element Service element description
Youth targeted suicide risk identification and prevention
The purpose of this element is to support existing community-based suicide risk identification and prevention targeted at children and young people, through workforce training and education, particularly for system ‘gatekeepers’, and providing follow-up and support for young people who have self-harmed or attempted suicide.
Age-appropriate digital MH services The purpose of this service element is to provide online support services for children and young people experiencing, or at risk of, mild mental illness.
Early intervention services for young people at risk of severe mental illness
This service element will provide early intervention services designed for young people at risk of severe mental illness.
Clinician supported age-appropriate digital MH services
The purpose of this service element is to provide clinician supported online mental health services for children and young people with moderate mental illness.
Children and youth focused brief psychological interventions
The purpose of this service element is to provide brief, focused psychological services for young people aged over 12, who are experiencing mild-moderate mental illness.
GP-led care coordination (e.g. Doctors in Schools)
The purpose of this element is to provide clinical care coordination for young people aged 12-25 with a mild-moderate mental illness.
Linkages to broader social supports The purpose of this service element is to link children and young people experiencing mild-severe into the broader social supports necessary to lead a meaningful life, including vocational support and AOD services.
Family Mental Health Support Services The purpose of this service element is to improve mental health outcomes for children and young people by supporting families and young people who are at risk of, or experiencing mental illness.
Extended children and youth focused psychological interventions
The purpose of this service element is to provide additional psychological interventions for children and young people experiencing a severe mental illness, whose needs are not sufficiently met through brief, focused psychological interventions. The service element will provide additional therapeutic interventions and/or support from clinical psychologists.
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Early intervention services for young people with severe mental illness
This service element will provide early intervention services designed for young people experiencing the early stages of severe mental illness.
Specialised complex care and support coordination
The purpose of this service element is to provide support for a mental health professional to provide a care coordination role for young people aged 12-25 with severe and complex mental illness, in community-based general practices, private psychiatrist services, and other appropriate services.
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SERVICES TARGETING SOCIALLY DISADVANTAGED POPULATIONS
Service element Service element description Targeted resilience building and mental health literacy programs
The purpose of this service element is to provide targeted health promotion to support resilience building and mental health literacy within key cohorts.
Cohort-targeted suicide risk identification and prevention programs
The purpose of this element is to support and supplement existing community-based suicide risk identification and prevention (with a focus on socially disadvantaged cohorts) through workforce training and education, particularly for system ‘gatekeepers’, and providing follow-up and support for adults who have self-harmed or attempted suicide.
Affordable and accessible brief psychological interventions
The purpose of this service element is to provide brief, focused psychological services for people in financial hardship who are experiencing mild-moderate mental illness.
Cohort-specialised GP-led care coordination The purpose of this element is to provide clinical care coordination for adults with a mild-moderate mental illness.
Active outreach and engagement services for hard-to-reach populations
The purpose of this service element is to provide additional support for engagement activities and outreach services for hard-to-reach populations.
Linkages to cohort-appropriate social supports
The purpose of this service element is to link socially disadvantaged people experiencing mild-severe into the broader social supports necessary to lead a meaningful life, including vocational support and AOD services.
Affordable and accessible extended psychological interventions
The purpose of this service element is to provide additional psychological interventions for adults in target cohorts experiencing a severe mental illness, whose needs are not sufficiently met through brief, focused psychological interventions.
Cohort-specialised complex care and support coordination
The purpose of this service element is to provide support for a mental health professional to provide a care coordination role for people from targeted cohorts with severe and complex mental illness, in community-based general practices, private psychiatrist services, and other appropriate services.
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ABORIGINAL AND TORRES STRAIT ISLANDER SERVICES
Service element Service element description
Aboriginal and Torres Strait Islander targeted cultural strengthening and social and emotional wellbeing programs
The purpose of this service element is to provide social and emotional wellbeing programs. These programs are designed to engage Aboriginal people in developing resilience and protective factors through cultural strengthening.
Aboriginal and Torres Strait Islander targeted suicide risk identification and prevention programs
The purpose of this element is to support and supplement existing community-based suicide risk identification and prevention for Aboriginal and Torres Strait Islander people through workforce training and education, particularly for system ‘gatekeepers’, and providing follow-up and support for adults who have self-harmed or attempted suicide.
Culturally appropriate, self-directed digital MH services
The purpose of this service element is to provide online support services for Aboriginal and Torres Strait Islander people experiencing, or at risk of, mild mental illness.
Culturally appropriate Natural supports Mental Health Support Services for young people
The purpose of this service element is to improve mental health outcomes for Aboriginal and Torres Strait Islander children and young people by supporting families and young people who are at risk of, or experiencing mental illness.
Clinician/AHW supported culturally appropriate digital MH services
The purpose of this service element is to provide supported online mental health services for Aboriginal and Torres Strait Islander people with mild-moderate mental illness.
Culturally appropriate brief psychological interventions
The purpose of this service element is to provide culturally appropriate, brief, focused psychological services and other culturally appropriate psychological interventions for Aboriginal and Torres Strait Islander people in financial hardship who are experiencing mild-moderate mental illness.
Culturally appropriate GP-led care coordination
The purpose of this element is to provide clinical care coordination for Aboriginal and Torres Strait Islander adults with a mild-moderate mental illness. This service element will provide additional support for workforce development to enable GPs to provide effective care coordination across multiple morbidities and services.
ACCHO-led care coordination The purpose of this element is to provide clinical care coordination for Aboriginal and Torres Strait Islander adults with a mild-moderate mental illness.
Linkages to cultural and social supports The purpose of this service element is to link Aboriginal and Torres Strait Islander people experiencing mild-severe into the broader social supports necessary to lead a meaningful life, including cultural and social and emotional wellbeing services.
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Culturally appropriate extended psychological interventions
The purpose of this service element is to provide additional psychological interventions for Aboriginal and Torres Strait Islander adults experiencing a severe mental illness, whose needs are not sufficiently met through brief, focused psychological interventions.
Culturally appropriate complex care and support coordination
The purpose of this service element is to provide support for an appropriately qualified mental health professional to provide a care coordination role for Aboriginal and Torres Strait Islander people with severe and complex mental illness, in community-based general practices, private psychiatrist services, ACCHOs, and other appropriate services.
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APPENDIX A REFERENCES
REFERENCES CITED
Commonwealth of Australia. (2010). National Standards for Mental Health Services.
Department of Health. (2015). Australian Government Response to Contributing Lives,
Thriving Communities: Review of Mental Health Programmes and Services
Department of Health. (2016a). PHN Mental Health Guidance: Aboriginal and Torres Strait
Islander Mental Health Services
Department of Health. (2016b). PHN Mental Health Guidance: Consumer and Carer
Engagement and Participation
Department of Health. (2016c). PHN Mental Health Guidance: Low Intensity Mental Health
Services
Department of Health. (2016d). PHN Mental Health Guidance: Psychological Therapies
Provided by Mental Health Professionals to Underserviced Groups
Department of Health. (2016e). PHN Mental Health Guidance: Regional Approach to
Suicide Prevention
Department of Health. (2016f). PHN Mental Health Guide: Child and Youth Mental Health
Services.
Department of Health. (2016g). PHN Primary Mental Health Care Guidance: Stepped Care
Department of Health. (2016h). PHN Primary Mental Health Care: People with Severe
Mental Illness.
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Department of Health. (2016i). Primary Health Network: Grant Programme Guidelines -
Annexure A1 Primary Mental Health Care
Department of Health. (2016j). Primary Health Networks: Grant Programme Guidelines
Department of Health and Human Services. (2015). Victoria's 10-year Mental health Plan
Department of Social Services. (2015). Family Mental Health Support Services Retrieved
from https://www.dss.gov.au/our-responsibilities/mental-health/programmes-
services/family-mental-health-support-service-fmhss
Harris, M., et al. (2016). Rapid Literature Review: Primary Mental Health Care Models
Mazza, D., et al. Identifying the Most Effective Models of Care for the Management of
Mild to Moderate Depression in Primary Care: A rapid review, Department of
General Practice, Monash University.
Mazza, D., et al. (2016). Identifying the Most Effective Models of Care for the
Management of Eating Disorders in Primary Care: A Rapid REview
National Disability Insurance Agency. (2015). Final Project Scope: Outcome Measures and
Reference Packages for Psychosocial Disability
South Eastern Melbourne PHN. (2016). South Eastern Melbourne PHN: Needs Assessment
Reporting Template - Mental health
The Black Dog Institute. (2016). An Evidence-based System Approach to Suicide
Prevention: Guidance on Planning, Commissioning and Monitoring