T-MOP Together for the Mental health of Older People A network
project on the Southern Fleurieu and Kangaroo Island Region
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Partners Southern Adelaide-Fleurieu-Kangaroo Island Medicare
Local Southern Fleurieu and Kangaroo Island Positive Ageing Task
Force Country Health SA Local Health Network Mental Health Services
Flinders University
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The problem Mental health issues in the older population are
frequently associated with co-morbidities Access to care can be
difficult multiple services different views on care
responsibilities Collaboration between services is needed because
of complexity of needs
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Project questions 1. What organisational linkages currently
exist in a rural region for the provision of mental health care for
older people? 2. What are the gaps, barriers and enablers in
linking services, as perceived by key stakeholders, consumers and
their carers? 3. What linkages could be established between
services for the mental health care of older people? 4. What
network planning and management model would be practical for
providing mental health care to older people?
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What will happen
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Who we interviewed Aged Care/Community services Primary
Care/General Health Mental Health/Dementia Care Victor
Harbor/Goolwa Residential Facility Caring Neighbourhood Programme
Alexandrina Centre for Positive Ageing ECH Therapy Programmes
Gospel Centre Medical Practice Goolwa Medical Practice Victor
Harbor Community Health Private mental health worker South Coast
District Hospital Mental Health Service Dementia Services 14
Yankalilla ACH Community ServicesMedical Practice 2 Kangaroo Island
Community Health Medical Practice Mental Health Service3
Strathalbyn Carer Wellness CentreMedical Practice Strathalbyn
Community Health Mental health Service4 Regional Positive Ageing
TaskforceSAFKI Medicare Local Aged Care Assessment Team 3 Total
26
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Local Level Suggested opportunities for change: Formalise a
feedback mechanism about client referrals between community aged
care services and GPs to promote consistency of communication e.g.
development of a template for use by different organisations.
Provision of an educational program facilitated by Nurse
Practitioners or Clinical Practice Consultants to educate agencies
on the importance on providing feedback, including identifying who
should be included in this process. Setting up a virtual meeting
space to share resources and local knowledge about what services
are available and eligibility, and for a library of resources. It
was considered that actions at level 1 could be achieved with
current resources.
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Management Level Suggested opportunities for change: Up
skilling support workers to identify and report decline in older
peoples function & mental state. It was noted, however, that
since 2011 the Positive Ageing Taskforce has run a number training
courses and so the issue might be to determine continued need and
approaches to this.. Engage leadership at higher levels to support
workers participation in beneficial networking activities (eg
important committees & meetings). Shared electronic case notes
across disciplines/services. Increased access to
psycho-geriatricians (including via video conferencing) and
geriatricians/memory clinics in local hospitals.
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Management Level cont. Suggested opportunities for change:
Consider the roles, current resources and organisations appropriate
to provide assessment and sign-posting of referrals for older
people across a range of mental health and related problems that
are dealt with by RCFs, GPs and other services. Acknowledge those
staff with important local network leadership functions by
recognising this in their role. Actions at level 2 require
champions to work with management and focus on specific, do-able
and relatively sustainable actions within the constantly changing
policy environment.
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Policy and Funding Level Suggested opportunities for change:
Broaden use of MOUs to facilitate effective linkages e.g. use MOUs
between aged care package providers and referring agencies to
require that feedback occur after the referral. Local government
provide a voice for aged care and mental health issues when
developing local health plans. Lobby policy makers regarding the
limitations of the current Medicare funding model e.g. limits on
the role of the practice nurse as case manager and GPs ability to
attend care planning meetings. Actions at level 3 would require
connections with existing older persons lobby groups to put mental
health on their agenda.
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What next? Road show presentation to individual services/groups
Client Journey interviews Senior Leaders interviews Final workshop
20 th November
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Social Media Updates Flinders University blog address:
http://blogs.flinders.edu.au/tmop/ SAFKI Medicare Local twitter
account: @safkiml