case. Stigma and common misconceptions surrounding mental illness often result in consumers not accessing mental health services until episodes have reached a more severe level (Meadows et al, 2009). No matter when a consumer presents to services it is important that we view the consumer as sitting within a continuum of care, with an understanding that treatment involves several phases of care with the view to providing a recovery based service (Australian Health Ministers, 2003).
Generally individuals fit within a continuum in the following manner:
(Commonwealth Department of Health and Ageing, 2000)
The arrows in this diagram point both ways because it is not a linear process. Many consumers move in both directions from the community to inpatient acute care and then back to community based intervention and so on. Some stages of illness require acute care whereas others don’t. When working in a recovery-focused way, clinicians should always bear in mind that recovery is the main goal of intervention.
But what do we really mean by recovery?
Read the relevant pages of your Meadows text about recovery and supporting recovery in Chapter 17
What is your definition of recovery? How do you envisage your role in helping the consumer with their recovery process?
Recovery can be viewed as a journey through differing types of care (Meadows et al, 2012). It often starts with the mental health issue being diagnosed and care being offered to the consumer within the community, if at all possible.
If this is not sufficient, the consumer may receive acute care in hospital as an inpatient. Following a period of acute care, there needs to be a period of rehabilitation which may involve both inpatient and outpatient care. This is then followed up by community support, with a focus on relapse prevention.
It is important during all these stages that clinicians work closely within their treating teams and make clear the role they are playing in the recovery process. Clear consistent messages are important during the whole treatment process, as relapse prevention work towards the end is reliant on consistent messages throughout the treatment process.
Community based intervention
Assuming for a moment that the assessment stage suggests that care within the community is appropriate for the consumer, there are two main types of intervention that are possible:
• Therapy or the use of suitable focused psychological strategies
• Advocacy and social support
These two main types of intervention are conducted within the context of interdisciplinary collaboration and planning.
When planning therapy it is important to consider the client in their entirety (Meadows et al, 2012). The following should be considered prior to planning any therapy with a consumer:
• Is the consumer willing to continue with therapy for the time required?
• What psychosocial issues may prevent therapy from succeeding? (eg. geographical isolation and low income preventing travel)
• Is the client sufficiently safe and secure in order to reduce stress to the point where therapy can succeed?
• Does your service have the resources to provide the therapy needed for the period it is required?
Quite often these issues create barriers to treatment and provide many clinicians with a very difficult decision: what do you provide to a client when the most obvious evidence-based intervention is not a viable option?
When therapy is unable to progress for one of these reasons, a mental health practitioner can do two things. First, they can work to mitigate risk and build rapport with the client. Rapport is often the greatest indicator of successful outcomes, more so than the type of therapy used (Hernandez et al, 2007). Mitigating risk, by addressing practical issues and improving the consumer’s day-to-day living arrangements, is an important intervention in its own right. It provides an increasingly safe environment for the consumer and helps to build a collaborative relationship, thereby laying the foundation for future therapies (Miller & Rollnick, 2002). Secondly, they can provide psychoeducation in order to improve the consumer’s insight, motivation, and commitment to therapy (Miller & Rollnick, 2002).
Advocacy plays an important role in the process of intervention. Depending on your role there are a number of ways in which advocacy on behalf of consumers and their families forms an integral part of intervening. There are number of ways in which this can occur (Meadows et al, 2012):
• Advocacy for clients experiencing discrimination as a result of their diagnosis in areas such as employment and housing. Quite often this form of advocacy involves assisting employers, landlords etc, to think creatively about how they do business and to educate them about misconceptions they may have about the inability of mental health consumers to undertake employment or tenancies.
• Advocacy for clients who are prevented from entering other services due to their mental health diagnosis. For example, older people with a mental health diagnosis have difficulty accessing aged care facilities due to the perceived level of care they require. Advocacy for equal rights to access other services is often key to successful placement of those with complex needs beyond a simply mental health diagnosis.
• Advocacy within the treating team for consideration of holistic approaches to care. Often it can be that the most prominent issue or aspect of a consumer’s presenting profile receives the most attention with more subtle yet equally important aspects (often psychosocial) receiving less attention. Depending on your discipline you may need to advocate for consideration of less recognised factors in care planning. For example, you may be advocating for extended stay on the grounds of housing difficulties that would undermine a consumer’s ability to continue treatment, whilst other members of the team may focus more on pharmaceutical treatment in the context of the inpatient unit without thought to how that will continue in the context of returning to an unstable home.
• Advocacy on behalf of families and carers. Family and carers are often responsible for providing treatment on a much more regular basis that the health professionals involved in care. Therefore it is often necessary to advocate on behalf of families and carers within the treating team, to ensure that plans made by the team take into consideration the attitudes and abilities of those who will be providing care long-term.
Interdisciplinary collaboration and planning is essential in the ongoing treatment of consumers (Meadows et al, 2012). In NSW (other states have similar clinical documentation, please refer to local forms for equivalents) MHOAT forms provide a care planning and review structure that assists clinicians and teams to plan care for consumers (NSW Department of Health, 2008). It is essential that these forms be completed and reviewed on a regular basis. For inpatient units care planning and review must be done on a weekly basis, with more detailed reviews every 21 days. For community teams it must occur every 12 weeks. This process ensures treatment remains focused and takes into account changes in the consumer’s mental state and life circumstances.
Chapters10, 14, 16 and 17 of your Meadows text.
• Chapter 10 covers the roles of the mental health nurse, the psychiatrist, the social worker, the OT, the psychologist, and the GP in the field of mental health.
• Chapter 14 covers case management and looks at the different roles for nurses, OTs, psychologists, social workers, psychiatrists and psychotherapists within case management. Each team needs a case manager to co-ordinate the roles of the various mental health practitioners. In a well functioning team, it is often difficult to tell the professional backgrounds of the various members of the team as they work together for the benefit of the consumer.
• Chapters 16 and 17 cover more detailed explanations of intervention and rehabilitation models.They demonstrate that rehabilitation is a wider concept than treatment, since it covers practical assistance with meeting basic human needs, employment and social skills training, as well as day-to-day living skills. Thus providing treatment is a much broader concept than simply providing therapy or drug treatment.
If you are interested in understanding the treatment options for various mental health disorders, you might like to read Chapter 18 onwards. Each chapter covers a different disorder eg. Chapter 18 covers personality disorders, Chapter 20 covers developmental disabilities and psychiatric disorders etc
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Last modified: Wednesday, 25 February 2015, 12:15 PM
7. Crisis management: involuntary intervention
When a consumer is facing a crisis of some kind, it is necessary to intervene in terms of crisis intervention. When the consumer is experiencing a psychotic episode, or is a danger to themselves or to other people, this may necessitate involuntary hospitalisation.
There are a number of options available to clinicians who feel that involuntary intervention is necessary.
Conditions for involuntary intervention
• First and foremost in order to ethically apply coercive practices, a clinician should be satisfied that risks posed to a consumer or those around them cannot be remediated any other way.
• They also should be certain that the reason for this situation is directly related to cognitive impairment as a result of mental illness, disability, organic syndrome or brain trauma. That is to say, clinicians have no ethical grounds to treat consumers who have capacity to make informed choices as involuntary patients just because their choices are not considered to be appropriate by others. This could include choices such as sexuality, religious affiliation or drug and alcohol abuse (Attorney General of NSW, 2008).
Formal involuntary treatment is designed with a number of checks and balances to ensure the rights of consumers are upheld (NSW Minister for Health, 2007). This is in comparison to informal methods of coercion such as the common practice of holding people voluntarily with the promise that if they try to leave they will be scheduled. Whilst on the surface this is described as least restrictive care, what is actually happening is that a consumer is being coerced to stay without independent inquiry into the appropriateness of the involuntary treatment. Ethically this is a very dangerous practice and should be avoided. In other countries patients have successfully brought lawsuits against hospitals that engage in this practice.
Forms of involuntary treatment
The four major types of involuntary treatment are:
• Involuntary admission
• Community Treatment Orders
• Financial management orders and
• Guardianship orders.
The following descriptions are current for the state of NSW. There may be variations to this information depending on state law. Take time to investigate these orders and their implications in your state or territory.
admission is the process by which a consumer is kept against their will in a mental health facility. There are a number of different orders depending on the length of time that they are detained, and the level of assessment and treatment that has been completed. As a general rule, the longer a consumer has been (and is to be) detained, the higher the number on the order (e.g., S22 is a minor order compared to S33). Please refer to the NSW Mental Health Act 2007 for a complete explanation of Mental Health Act orders (NSW Minister for Health, 2007).
Orders of more than a week are generally made by either a magistrate or a tribunal. When presenting a case, clinicians must prove that there is significant risk posed to a consumer if they do not receive treatment and that a treatment plan that addresses these risks is in place. Community treatment orders also sit within state Mental Health Acts. These are orders that spell out not only the responsibilities of the consumer in terms of their ongoing care in the community, but also the responsibilities of the mental health team providing care. They will typically spell out the required medications, the frequency of appointments, and any other conditions that may be necessary to maintain mental health and wellbeing, such as abstinence from drugs and alcohol.
Diagram source: http://www.audit.vic.gov.au/publications/2002/20021017-Mental-Health-Services-for-People-in-Crisis.pdf
Community treatment orders
There are a number of things to consider when planning for community treatment orders:
• Are the conditions enforceable? That is, can you as case manager ensure that the consumer is complying? If the consumer is on oral medication three times per day, how will you make sure they are taking the medication? With some medications (such as Clopine or Lithium) blood levels can be taken to monitor compliance. In other cases it is necessary to consider medication administered fortnightly or monthly by a clinician who agrees to monitor compliance.
• Will you be prepared to breach someone if they fail to meet part of the community treatment order? If the therapist would not be willing to take the consumer back to hospital if they missed a therapy session, then this condition should not be included in the order.
• Does the client have a history of non-compliance? Tribunals will need to see evidence of non-compliance in the community, before they will authorize a community treatment order.
Guardianship orders (including financial management orders) are designed for people who do not have capacity to make informed decision regarding aspects of their lives. The following information is current in the state of NSW. If you are not practising within this jurisdiction, you should check your own state’s guardianship laws for any changes or major differences.
Guardianship orders for people with mental illness have been found to be just as beneficial for mental health consumers as community treatment orders, particularly in cases where consumers have complex Axis 4 diagnoses (Carney & Tait, 1997). In order to seek a guardianship order, clinicians must prove that the consumer lacks the capacity to make informed decisions and that there are significant decisions that need to be made in order to improve their health and wellbeing (Attorney General of NSW, 2008). For mental health consumers, common reasons for lack of capacity include:
• Delusional disorders
• Frontal lobe impairment leading to impulsivity
• Emotional disregulation leading to impulsivity
• Chronic psychiatric impairment
• Body dysmorphic syndromes
When applying for an order, it is important for clinicians to identify in which areas they wish to seek a substitute decision maker or guardian. The areas in which a substitute decision maker can be appointed are (Attorney General of NSW, 2008):
• Medical treatment and procedures (including dentistry)
• Access to services (such as home care, meals on wheels, psychiatric rehabilitation)
• Who is permitted to have contact with the consumer (normally used to protect consumers from exploitative and violent relationships)
It is also necessary to determine whether there is a family member or carer who is suitable and willing to undertake the guardianship role, or whether a public guardian must be appointed. One must also decide whether the appointed person will need to be given coercive powers in order to undertake this role or whether the client will be willing to abide by decisions voluntarily (Attorney General of NSW, 2008).
READ: Meadows et al (2012) pp 445-8 about CTO’s
When discussing involuntary treatments we often forget that the process of obtaining an order involves both clinicians and consumers entering the legal system.
Hearings are set up as in a criminal court room, with the clinician on one side and the consumer (and sometimes a lawyer) on the other. The magistrate or tribunal is at the front and, at the discretion of the magistrate, family members and carers may or may not be allowed to attend.
• What impact do you think this has on the consumer and their relationship with their treating team?
• What messages do you think this sends to consumers about the nature of their situation?
• How could this process be differently approached to make it more consumer friendly?
8. Medication and ethics of care
Pharmaceutical interventions are a major part of work within the mental health system (Meadows et al, 2012). However as demonstrated throughout this unit, medication is used within a much larger context of care. When planning occurs around medications, it is important that decisions are made as a team.
The following factors should be taken into account when planning around pharmaceutical interventions:
• Can the consumer reasonably afford the medication being prescribed? Some medications used in psychiatry are only on the pharmaceutical benefits scheme for specific diagnoses, despite their more broad use. Clearly prescribing medications which are financially prohibitive will not assist consumers in compliance.
• Will the consumer be placed on a treatment order? If so, does the medication prescribed allow for monitoring?
• Does the consumer have a history of deliberate self-harm? If so, is the medication being prescribed likely to be used in a future suicide attempt? If this is a possibility then consideration might be given to clinician-administered injections or, if the drug must be taken orally, to arranging for a pharmacist to dispense only small amounts of medication at a time.
• Does the consumer have a history of substance misuse? If so, some thought must be given on avoiding medications which may cause dependency or increased potential for abuse, such as benzodiazepines and dexamphetamine.
Ethical practice when providing treatment is essential for a number of reasons. Most importantly, ethical practice ensures that consumers are treated respectfully and their best interests are maintained at all times (Meadows et al, 2012). Another reason why it is important that you understand and work by your profession’s code of ethics is that it provides protection for you as a worker. The consequences for people who do not adhere to prescribed codes of ethical conduct can be deregistration and, on occasion, expulsion from practice.
Whilst each discipline has its own set of ethics which you should all be familiar with, there are some ethical principles and considerations that all clinicians should be familiar with before providing treatment to consumers:
• Pharmaceutical company promotion. Pharmaceutical companies invest significant amounts of money into promotion of their products. This can range from branded stationery through to free dinners and clinician retreats. Whilst these promotions can be appealing, a clinician’s intervention should be evidence-based. Clinicians should avoid any perceived conflicts of interest by reducing their reliance on promotional products.
• Clinicians should always provide balanced information to consumers. It is tempting to gloss over the negative side effects of medications in order to encourage medication compliance. However, consumers should always be made aware of the negative side effects of treatment in order to make informed decisions about their care.
• When consumers are assessed as having capacity to make informed decisions, clinicians should be careful not to withhold information or manipulate consumers into making particular decisions based on the clinician’s beliefs about what should happen.
Review your own profession’s code of professional ethics and think about issues about which you have a strong moral belief.
• How would you manage a situation in which your moral code and professional code differed?
• What would be an example of this situation for you?
READ: Meadows (2012) pp 47-49 discussing the Ethical Underpinnings of Health Care Delivery
Last modified: Wednesday, 25 February 2015, 12:20 PM
• 9. Managing comorbidity and complex casesPage
9. Managing comorbidity and complex cases
Mental health issues do not occur in isolation. Mental illness occurs within a context, and the level of complexity can often be overwhelming.
When managing cases of co-morbidity, it is important to begin with a thorough assessment of the consumer (Meadows et al, 2012).
When conducting this initial assessment it is important to paint a full picture of the consumer and their experiences in context. It is also important to get an appreciation of the relationship between different issues the consumer faces. For example, if a consumer has alcohol dependence and a problematic relationship with their partner, it is important to establish how the two are connected. Does the consumer drink to cope with the stress of the relationship, or does the consumer’s drinking cause the relationship breakdown? Once a fuller picture of the consumer is determined, it is then possible to begin to address each issue based on your greater understanding of the consumer’s situation as a whole.
Multiple agency involvement
When managing complex cases there is more often than not the need for more than one agency to be involved. When working with cases involving multiple agencies it is important to consider the following practical measures to ensure the best outcomes for consumers:
• Designate a lead agency: When providing collaborative interventions a lead agency or worker should be identified to perform coordination tasks such as convening case conferences and handling management of the overall treatment.
• Communication: The lead agency or worker should ensure that appropriate permissions are gained for agencies to share information regarding the consumer with other workers involved in providing care. This establishes a culture of openness and transparency and prevents consumers from shopping between workers for desired outcomes.
• Case conference: Before any treatment begins it is important to facilitate a case conference involving all concerned parties, including the consumer (although the consumer may be present for only a part of the meeting). During the conference, attention should be given to the following matters:
o Clearly defining roles and responsibilities of all parties.
o Outlining treatment goals.
o Establishing communication protocols.
o Developing a shared understanding of the consumer and the interventions needed.
o Determining time frames for intervention.
o Setting up review dates for further case conferences (Arkowitz et al, 2008).
One of the disadvantages of multiple agency involvement is that differences between agencies (for example, in areas such as underlying philosophy and staff skill levels) can often lead to consumers receiving mixed messages, which in turn can negatively impact on consumer outcomes (Arkowitz et al, 2008). The alternative is to provide integrated care: that is, that one agency works to meet all the major needs of the consumer simultaneously. Whilst this method of working is not always possible, it does have these advantages (Arkowitz et al, 2008):
• It reduces the complexity of arranging care.
• It reduces the burden on consumers to attend multiple appointments.
• It simplifies the messages being given to consumers.
• It assists with consumer engagement by reducing the number of people consumers need to engage with.
• It reduces the time burden on services by eliminating the need to coordinate communication across agencies.
Providing integrated care within mental health treatment involves clinicians using therapeutic exchanges to address multiple issues. For example, whilst providing psychoeducation on mental health diagnosis, the clinician can speak about the effect substance misuse can have on illness progression (Arkowitz et al, 2008). Working in an integrated manner does not mean a clinician must hold more information necessarily. The clinician should be aware of avenues to go to seek out further information when the need arises.
One aspect of managing complex cases involves the challenges of those consumers who present with chronic risk factors. Most commonly this is seen in cases of ongoing and chronic suicidality and self-harm.
Managing chronic risk presents several challenges for mental health clinicians:
• Chronically at-risk consumers cannot stay in mental health units forever.
• Staff often feel ‘stuck’ and unable to offer a solution.
• Staff experience anxiety that should something happen they will be held responsible.
It is important to accept that in some cases there is no solution to this issue. Instead it can be helpful to focus on safety planning and providing mechanisms for intervening when risk is at its greatest. This often involves multi-agency collaboration, as described above, to provide a system around the consumer to mitigate the risk as much is possible. However, there is a need to accept that there will always be a level of risk, despite the best efforts of the treating team.
Substance use and mental illness – a motivational interviewing approach
The most common example of co-occurring disorders in mental health is a DSM-IV-TR diagnosis and substance abuse issue. This makes up between 80 and 90 percent of all mental health presentations (Arkowitz et al, 2008). Given this large percentage, it is often the case that an integrated approach to care is most appropriate for these consumers (Rollnick et al, 2008).
The other challenge, of course, is that clients are not always motivated to change their substance use and mental health behaviours (Diclemente & Prochaska, 1998). With this understanding clinicians can rely on the principles of motivational interviewing and the cycles of change in order to assist in providing integrated interventions to these consumers (Diclemente & Prochaska, 1998). This approach is described in HSMH423 in detail and is also outlined in this resource.
READ; Meadows (2012) pp 29-30
• 10. Planning care for diverse consumersPage
10. Planning care for diverse consumers
Working with diversity
Mental illness does not confine itself to one particular type of person, and working with a diverse range of people requires a significant level of skill in empathy and understanding on the part of a clinician to ensure that services are provided in a client-centred way (Meadows et al, 2012).
Assessment is a crucial time when clinicians should seek to look beyond a simple diagnosis to also understand how the current illness has arisen in the context of the client’s life.
When considering diverse cultures it is important to understand how the client and their broader culture perceive mental health issues. For example, in some indigenous communities, when a person experiences a mental illness it is considered that the whole family is unwell and therefore must all be involved in the healing, and in some Indian cultures people with mental illness are seen to have been closer to their gods.
Understanding how the consumer conceptualises their diagnosis allows for greater understanding of how best to assist them. For example, understanding that some indigenous cultures experience a diagnosis as a community implies that in order to appropriately progress treatment the client must be treated as part of a larger system, rather than as an individual.
It is not necessary, however, for the clinician to know the intimate details of every culture they may encounter. Instead clinicians should be familiar with basic engagement and effective listening strategies to allow them to gain insight into an individual and their way of seeing the world.
The role of families and carers
Family in this context is defined as anyone committed to the care and support of the person with a mental health issue and does not have to be a blood relative.
A carer is a person whose life is affected by virtue of his or her close relationship with the consumer, or who has a chosen and contracted caring role with the consumer (usually unpaid) (NSW Minister for Health, 2007).
The Mental Health Act of NSW (2007) has identified that family and carers play a significant role in the health and wellbeing of consumers (NSW Minister for Health, 2007). There is evidence that family interventions can be as successful as other mental health interventions and have benefit across most DSM-IV-TR diagnoses (Mottaghipour & Bickerton, 2005). The Mental Health Act 2007 has made special allowances to increase the involvement of families and carers in treatment and information sharing (NSW Minister for Health, 2007).
On admission to mental health units, consumers are required to identify a primary carer who is given increased powers to be involved in all stages of care and treatment. With this increase in access comes a greater need to provide support for families and carers to assist them to be involved effectively in the care process (Furlong & Leggatt, 1996).
Typically families report that they want the following from service providers (Mottaghipour & Bickerton, 2005):
• Information & education about the illness
• Access to service providers
• To be valued as part of the treating team
• Specific suggestions for coping with the consumer’s behaviour
• Emotional support
• Access to people who face similar problems
• Timely crisis intervention
• Respite services
• Alternative living options for the consumer
• Meaningful involvement in treatment, discharge & rehabilitation planning
• Information & education about the mental health service
Integrating family work into practice
The Cumberland model of integrated family practice (Mottaghipour & Pickerton, 2005) provides a framework for all clinicians in providing assistance to families.
4. Mental health plans and the continuum of care
How are care plans developed and documented for consumers with mental illness? What are appropriate treatment protocols? How can treatment be shared effectively among health professionals in different sectors to guarantee continuity of care for consumers? Why is the skill of appropriate documentation so important?
• 1. Integration of mental health care and providing continuity of carePage
. Integration of mental health care and providing continuity of care
Providing integrated services is essential for the success of treatment. The catchcry for integrating services, before, during and after hospitalisation is ‘seamless continuity of care’. Achieving this is difficult because of the different teams of health professionals taking responsibility for care at different stages of the illness episode and each believing that their stage is the most important. However we must try to work to the principles of continuity of care identifed by Meadows et al, (2012).
The nine principles of continuity of care are:
• Supportive administrative processes
• Accessibility of the service to consumers
• Comprehensive service availability
• Individualised approach to treatment
• Flexible programs
• Linkage to other agencies
• Valued consumer/case manager relationships
• Culture of collaboration between staff and consumers
• Cultural sensitivity
When planning care there are a number of strategies that can be employed in order to provide seamless transitions from one period of care to another:
• Standardised formatting of clinical documentation.
• Integrated clinical record keeping.
• Clearly defined roles and boundaries for care.
• Effective discharge and assessment procedures.
• Effective case conferencing at the points of entry and exit from a particular phase of treatment.
• Consumer involvement in all stages of care planning (when possible).
• Comprehensive assessment and discharge documentation.
In essence, continuum of care relies predominantly on clear and effective communication and methods of working that allow all pertinent treatment data to flow between all parties involved in the care and treatment of clients. Whether treatment is carried out by one service or by multiple services it is important that treatment proceeds along the continuum in a seamless and logical manner in order to assist clients in achieving better outcomes over time.
READ: Meadows et al (2012) pp 222-225 discucusses continuum of care as a quality improvement framework
Last modified: Wednesday, 25 February 2015, 12:34 PM
• 2. Referral, scheduling and discharge pathwaysPage
2. Referral, scheduling and discharge pathways
As mentioned throughout this unit, clients may have many medical and psychosocial needs. When planning for discharge from a service it is often necessary for clinicians to make decisions about referral pathways and discharge planning. The following are considerations that should be made in consultation with the client when arranging referral and discharge:
• The number of referrals or discharge destinations. Often clients have difficulties with organising multiple referrals with different appointments in various locations. It is important that the client and/or carer understands the need for these referrals and has the means (transport and money) to get to them. If this is not the case then the health profession has to make other arrangements for the client. Travel in rural areas is particular problematic and needs to be considered before discharge.
• Prioritising of issues. The prioritising of issues should be made in collaboration with other health professionals and the client before discharge.
• Provision of information. All relevant information that is necessary for the continuing care of the client should be forwarded to ongoing service providers.
In some instances it may be possible to have a joint interview with the discharging health professional, the health professional who is about to take up the on-going care, and the client. This personal introduction and passing the care of the client onto another health professional is the most efficient way to smooth the process of continuing care because it assists the client to feel comfortable with the staff and facilities in the next stage of care.
Last modified: Wednesday, 25 February 2015, 12:35 PM
• 3. Documentation and information systems in service deliveryPage
3. Documentation and information systems in service delivery
Documentation and recording systems are essential to ensure continuity of the care and are the responsibility of the health professional. All records should be clear, readable, clinically relevant, dated and signed and made in the records provided officially by the facility. These records are important for the health of the client and persist, so every care should be taken with them.
Principles of documentation
There are a number of universal principles for good documentation.
• Always ensure you time and date all notes.
• Always sign and print your name and include your designation and role.
• Never leave blank spaces. If you need to leave a space, draw a line through it.
• Always write in black pen.
• Protect the anonymity of others. If reporting on interactions with other clients, use generic terms (e.g. an elderly client) only.
• Be objective. Do not write about what you think or feel, and do not state something unless is proven or witnessed.
• Do not use whiteout. If you make a mistake, cross it out and initial the mistake.
In order to improve client care, all health services have reporting systems for incidents that are usually defined as ‘unplanned event/s resulting in, or having the potential for, injury, damage or other loss’.
Sentinel events are incidents agreed as key indicators of system failure by all States and Territories and defined by the Australian Council for Safety and Quality as ‘events in which death or serious harm to a patient has occurred’. As part of the investigation into these events Root Cause Analysis is undertaken. This is a process used to review and analyse an incident seeking to identify, as far as possible, all causal and contributing factors leading to the incident and to identify corrective actions to minimise risk of recurrence. The spirit of the investigation should not seek to blame but should seek to find and remedy the systemic reasons for the failure to provide appropriate care. The risk is often graded in relation to the level of harm involved and a Safety Improvement Program is developed and implemented.
Unfortunately in mental health services some incidents occur that require reporting and investigation. Examples would include: wrong medication given to a patient, patient absconding from involuntary care, suicide attempt while in care, violence and assault, needle stick injury, use of illegal drugs while in care, and inappropriate behaviour by staff.
Professional attention to documentation and record keeping is very important in mental health care.
The Mental Health Outcomes and Assessment Tool (MHOAT) is a standardised set of clinical records used throughout mental health services in NSW. Other states will have their own proformas but all are designed to ensure that each client is carefully assessed, treated, and discharged to on-going care experiencing the best mental health professional care possible. These documents provide guidance in relation to what should be recorded during the process of mental health care.
You should familiarize yourself with the MH-OAT guidelines provided on the Complementary CD-ROM. The MH-OAT forms are also reporting tools.
Similarly, different states will have different ‘care plans’. These are templates to record goals of care, strategies and interventions used, the person or service responsible, the expected date of completion, the date of review and the measure of evaluation.
Identify in your area of work the official documentation used for care plans and the policies and programs involved.
The NSW mental health care plan template is provided for your information.You will see that in this document there is only space for recording short titles of treatment or the name of an intervention. For example:
• REFLECT & DISCUSSForum
REFLECT & DISCUSS
Identify the policies and programs that operate in your area of current or future work with respect to analyzing sentinel events. Could these be improved? How? In framing, in implementation or both?
Post your reflections to the forum below and respond to the reflections of your peers.
• 4. Improving safety and quality in the health care sectorPage
4. Improving safety and quality in the health care sector
The Australian Commission on Safety and Quality in Health Care (http://www.safetyandquality.gov.au/) was established by the Australian, State and Territory Governments to develop a national strategic framework and associated work program to guide its efforts in improving safety and quality across the health care system in Australia. (See: http://www.safetyandquality.gov.au/our-work/national-standards-and-accreditation/)
The Commission commenced on 1 January 2006.
The Commission’s role is to:
• lead and coordinate improvements in safety and quality in health care in Australia by identifying issues and policy directions, and recommending priorities for action
• disseminate knowledge and advocate for safety and quality
• report publicly on the state of safety and quality including performance against national standards
• recommend national data sets for safety and quality, working within current multilateral governmental arrangements for data development, standards, collection and reporting
• provide strategic advice to Health Ministers on best practice thinking to drive quality improvement, including implementation strategies, and
• recommend nationally agreed standards for safety and quality improvement.
The work of the Commission involves:
Accreditation: The primary objective of the project is to provide Health Ministers with an alternative model of accreditation that can be applied across all sectors of the health care system.
Australian Charter of Healthcare Rights: The Commission has worked with the Consumers Health Forum and other organisations to develop an Australian Charter of Healthcare Rights that provides information about the rights of patients and consumers to underpin the provision of safe and high quality care, and to support a shared understanding of the rights of people receiving care.
Clinical Handover: The purpose of this program is to identify, develop and improve clinical handover communication. Safe health care delivery for patients depends on effective communication between health care providers. Developing and implementing more consistent and reliable approaches to clinical handover is a key strategy to reduce communication errors.
Credentialling for health professionals
Falls Prevention: Guidelines preventing falls and harm from falls in older people: Best practice guidelines for Australian hospitals and residential aged care facilities
Healthcare Associated Infection (HAI): The aim of the Commission’s HAI program is to formulate a national approach to HAI including strategies for ensuring practices are sustained and the development of an agreed National Plan for healthcare-associated infection prevention. The project will focus on identifying and addressing systemic problems and gaps and ensuring a comprehensive range of action is undertaken in a nationally coordinated way by leaders, decision makers and public and private providers operating at different levels in the health system.
Information Strategy: The program will provide national leadership and coordination in national improvements to the evidence base for safety and quality, via the development, analysis, use and reporting of information that monitors and equips actions to enhance the safety and quality of health care. The program of work is set out in the Information Strategy. There are four streams of work, designed to achieve key aims for the Commission specified by Ministers and to support information developments required by other priority programs.
Medication Safety: The objective of this program is to improve the safety of medication usage in Australia. Effective and safe use of medication is one area where potential improvements in the safety and quality of health care can be made. Because of the multiplicity of current and proposed initiatives in this area, there may be a key coordinating role for the Commission.
Open Disclosure: Open disclosure is the open discussion of incidents that result in harm to a patient while they are receiving health care. The National Open Disclosure Standard (the standard) outlines the essential elements of open disclosure. The purpose of this project is to support jurisdictions and facilities to implement the standard. This will involve translating the findings of the national pilot of the standard into useful tools for clinicians and patients, and undertaking work to overcome the legal barriers to open disclosure and to explore patients’ experiences of open disclosure.
Patient Identification: This program is a national response to the continuing problem of patient misidentification. It is focused on key areas of activity where the Commission can deliver leadership for national action, coordinate agreed standards for performance, and support jurisdictions and private health providers in their implementation of protocols and agreed safety improvement actions.
Recognising and Responding to Clinical Deterioration: This program is to explore what national work can improve the safety and quality of care for the patients at risk of unexpected cardiac arrest or serious morbidity, including consideration of communication of critical test results.
Several of the publications available at the Commission web site provide important reading for health professionals.
We will end this module by asking you to read this article on Current issues in mental health service provision in Australia. Professor Cobie Rudd stresses the importance of safety and quality in mental health services, while Associate Professor Nicholas Procter emphasizes the importance of communication between health professionals, the client and carer in improving mental health services in Australia.
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