5.6: A Case Study
Implementing CCSM for mental health patients within a general practice in a rural area: a case study(1)
Introduction
This case study demonstrates an action research-based series of PDCA cycles which have been instituted within a busy country general practice (GP) in South Australia. It has been developed in a sustainable way for patients with mental health problems. It provides evidence-based, coordinated and planned care that is monitored according to a care plan. The study shows that it is possible to provide this care by means of the use of systematic care planning, consultant psychiatrist assessment and review, general practice responsibility and close collaboration with mental health nurses employed by the practice under the Mental Health Nurse Incentive Program (MHNIP). It has been associated with substantial changes in the ways that patients have been managed within the practice. The implementation of these positive changes has been externally evaluated on two occasions and is ongoing and a further PDCA cycle is currently under consideration.
Background
The delivery of evidence-based psychiatric care in general practice is difficult for many contributory reasons which include the high prevalence of these disorders, skill levels of and the competing demands on GPs, the historically separate state-based mental health care focused on psychosis and hospitalisation, stigma and resource deficits of manpower and support services in the community.
There are many barriers to effective care, created by the structure of general practice. The barriers include the patient-demand driven structure of the appointment system, time allocation for appointments which is less than adequate for patients with emotional distress and carries with it perverse financial incentives, the waiting time for expert psychiatric assessments and the problems in communication between the many agencies often involved in the care of these patients.
The behavioural disturbances of the patients may also create problems for the orderly conduct of general practice as a business at times. Failure to keep appointments, needing urgent appointments or longer sessions than booked times, can disrupt orderly schedules, and reception staff can feel less than competent to deal with disturbed behaviour of these patients and others who have been kept waiting. In rural general practice these problems are further magnified.
PDCA cycle 1
Plan
The psychiatrist was invited to visit the GP on a consultation basis and a referral model of care on a private practice basis, as a part of his limited rights to this as a senior staff Specialist Liaison Psychiatrist at a major teaching hospital. An application was made by the practice to enable sponsorship for ten sessions per annum with the support of the Medical Specialist Outreach Assistance Program (MSOAP) which defrays the costs incurred by the specialist for travel, service and accommodation. In this case study the selected psychiatrist was actively involved in teaching and researching chronic condition self-management (CCSM).
Part of the agreement with the GPs was that the psychiatrist would work as much as was possible as a support to the GPs. The aim was to avoid referral to tertiary care by using a care-planning approach, with case conferencing, comprehensive assessment and reporting being the main instruments. Secondly, an action research approach using plan-do-check (study)-act cycles (PDCA) within the normal practice development paradigm, methodology and business model of the practice was confirmed.
The visiting psychiatrist commenced in February 2005 with the initial agreement from the GPs to try to develop a coordinated care-planning approach for all referred practice patients.
Do
The psychiatrist made eighteen visits during that year. A total of eighty-one new patients were referred from the practice and fifteen from other regional GPs. For all eighty-one practice patients, the psychiatrist had recommended the development of a mental health, complex condition or shared care arrangements care plan which could be claimed from Medicare in addition to the usual billing item numbers.
Check
The review showed that in only twenty cases had follow-through been possible. The psychiatrist wrote to the Practice Manager indicating that from a financial point of view much of the work of comprehensive and integrated mental health or complex care had been carried out but the practice had not received an appropriate financial reward for this.
Act
The issue was discussed and the PDCA cycle was repeated to formulate a new plan of action.
Plan
A decision was made to apply for a practice development grant. The application was successful and allowed the employment of an experienced registered nurse without mental health expertise, to see what could be done to follow through recommendations by the psychiatrist to develop a care plan.
Do
The new initiative was for the nurse to work more closely with the psychiatrist at the time of the visit (lunch time and at the end of the day to discuss patients) in order to follow through, and to complete tasks to fulfill the criteria required for the care plan to be effected and the remuneration to be claimed. This was done by the psychiatrist sending a copy of the assessment letter to the practice nurse as well as the GP. The nurse then followed through by creating a draft care plan and drawing this to the attention of the GP. The nurse made an appointment for the patient to meet with the doctor to sign off on, and institute the care plan. One element previously missing was that a quantitative screening instrument had not been routinely used by the GP in order to claim the item number and this was remedied by the nurse administering the DASS 21.
Check
At the same time that the revised plan was put into practice, the Division of General Practice conducted a qualitative evaluation of the project. After three months of using the new system, all patients were being followed through by the practice for the development of a care plan. A number of events occurred that changed patient flow including the coordination of care and referral out to a community psychologist and mental health services. The opportunity of the MHNIP occurred at this time and was followed through by the practice, resulting in the accreditation of the practice and the nurse as part of the program, with the nurse working closely with the psychiatrist and the GPs.
Act
The new system was successfully implemented. It was agreed by the partners at three months that this arrangement was in fact financially viable and practicable in terms of space and demands on clerical staff. In addition GPs did not feel that their role with the patients was being usurped and the psychiatrist also found the role of the MHN to be supportive. Doctors were still clearly responsible for each of the patients and their management plan. It was agreed to trial this arrangement over a further twelve-month period.
Discussion
A new PDCA cycle was put into place to explore and develop the role, function and effects of introducing a full-time mental health nurse to the psychiatric services delivered by the medical centre. A triage function also developed for the mental health nurse, as did back-up educational and support services for the nursing staff at the Community Hospital when patients needed to be hospitalised. It also led to the MHN being over-booked, with a blowout of waiting times for her and the psychiatrist leading to the common problem of ‘clogged up’ clinical demand. This persisted even after a second MHN was employed.
The major issue confronting the ‘clogged-up’ clinical demand within this medical centre was the limited availability of the psychiatrist but also the failure for the medical centre to seriously address the issue of patient self-management skill development. The psychiatrist had suggested the implementation of the Flinders Program of Chronic Condition Self-management but the implementation has been considered an option rather than a necessity due to training cost and the implications for organisational change. However, it has now come to a time where each of the mental health nurses has reached the limits of efficient operation because of the low capacity for self-management by the more chronic and frequently relapsing patients. They place demand on the system and receive care that fails to address their self-management needs. The next PDCA cycle will focus on this issue. The MHNIP can be implemented by GPs or a psychiatrist in private practice employing MHNs and recharging the Commonwealth Department of Health and Ageing at $250 per three-hour session for their work.
One of the major problems in the provision of evidence-based care is the implementation of new knowledge within the real world of general practice as a business. This case study shows that it is feasible to establish and progressively implement an evidence-based, integrated and coordinated model of care within a country general practice. While it has been externally reviewed, formal evaluation and comparison to current best standard care for patients with mental illness could be conducted. This project is self-sustaining on a routine basis and is not simply a demonstration project which depends upon idealism and altruism, which although admirable, are not self-sustaining in the long term.
Reference
- Pols RG, Battersby M, Haydon D. Implementing self-management support in your practice: a case study in a rural general practice. Based on abstract and presentation at RANZCP 2010 Congress, Auckland.
