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*
A presentation byErnie Sorgini and Michael BailieMental Health,
SAAS and SAPOLDeveloping Seamless Communication with a Cost
Effective ApproachWestern Assessment and Crisis Intervention
Service (WACIS)
CPI ProjectCentral Northern Adelaide Health Service
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*Team MembersErnie Sorgini Team Leader Western ACIS - CPI
Project CoordinatorMichael Bailie Senior Social Worker Western ACIS
- CPI Project Coordinator Oleh Cybulka Chief Inspector Legislation
& Policy MH Liaison David ODonovan Chief Inspector Port
Adelaide LSAPaul Lemmer South Australian Ambulance ServiceHelen
Gregor Clinical Nurse - Mental Health Services - TQEH Emergency
Dept.Imelda Cairney Mental Health Nurse - Mental Health Services -
TQEHJohn Antonio - Team Leader Southern ACIS Sylvia Ebert - Team
LeaderMental Health Triage Service Amanda Porter MIFSA (Mental
Illness Fellowship of SA)plus ConsumerFiona Johnson - MIFSA (Mental
Illness Fellowship of SA)Philip Galley - Mental Health
UnitChristopher McCaskill CSC TQEH EDAnne Barbara Carer Consultant
Cramond Clinic plus CarerTim Gore CPI Team Support Glenside
HospitalMary Anargyros Well Ways programPeter McEntee S A Ambulance
ServiceWe would also like to thank our Executive, Ms Dianne Norris
and Ms Michelle Hilton for supporting this CPI Project and for
seeing the benefits.
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*Our Mission StatementThat in 6 months time if a mental health
patient (or potential mental health patient) has had a crisis visit
by SAPOL / SAAS, the Mental Health Triage / Mental Health Services
should be informed within 24 hours.The defined cohort of patients:-
will be aged between 18-65 years; may or may not be current clients
of the Mental Health Services and will reside within the western
metropolitan area of Adelaide within the Western Assessment and
Crisis Intervention Service area boundaries.The time frame for
completion is expected to be 30/9/2009.The project is to be
consistent with organisation and department strategic aims and
culture.
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*What is the Problem? SAPOL/SAAS usually do not contact the MHT
131465 Crisis Line before or after visiting a Western (potential or
known) mental health consumer
Consumers complaining about Triage response times.
Emergency Services complaining about triage response.
As a direct result of the above - SAPOL and SAAS will often
attend to a call (or convey a client to EDs) with no contact having
been made with the Mental Health Services. SAPOL/SAAS attending MH
presentations where MHS should be in attendance.
That there is ineffective communication between SAPOL / SAAS
& MHS. This impacts directly the on client (& others). Poor
communication effects client safety and the management of risk in
the community. Why?.... Key reported aspects by SAAS/SAPOL are : -
triaging of SAPOL / SAAS calls takes too long by MHT or - that they
are kept on hold for too long prior to speaking to an operator and
so hang up. They wont call 131365 (MHTS) as stats show in the next
slide
NB - There currently exists a Memorandum of Understanding (MOU)
Implementation Guidelines for Mental Health between SAPOL, SAAS,
RFDS & MHS (2006)
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*SAPOL attendances and Combined ACIS / SAPOL attendances (via
MHTS) Information sourced from SAPOL & WACIS figures 2009
Chart1
1349
1920
228300
9330
Hospital Emergency Departments
Number of ED Presentations
SAAS / SAPOL - Western Area Mental Health Only Conveyances to
Emergency Departments Jul 08 - Mar 09
Chart2
4141
692
2366
ACIS with SAPOL (Y)
SAPOL (Blue)
Attendances to MH Clients
Sheet1
SAASSAPOL
RAH1349
FMC1920
QEH228300
*OTHERS9330
ACIS with SAPOL (Y)SAPOL (Blue)
Sep-Dec 084141
Dec-Mar 09692
Mar-Jun 092366
Sheet2
Sheet3
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*Reduce time spent for SAPOL officers at hospitals due to
attendances that have been addressed by ERT attendance. Reduce
SAPOL / SAAS repeat home visit attendances. Improve MHS attendance
to acute settingsEasier access for SAPOL to contact MHTS or MHS as
needed. Improved feedback to MHS from SAPOL/ SAAS of client
contact. Improve statistics gathering due to contacts being
registered on CBIS.The identification of barriers to communication
with MHS by SAPOL / SAAS. Improve feedback communication by
Emergency Services to Mental Health after Emergency Services have
left the scene.
Benefits in rectifying the Problem
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* SAAS & SAPOL Western (Port Adelaide area sample) Area
Mental Health Clients Only -Conveyances to E.D.sRAH - 158 9 167QEH
- 294 300 594FMC - 226 N/A(Only local LSA) OTHER - 94 30 124
TOTAL:- 772 339 111153.5% of total # went to QEH.* Others = WCH,
LMHS, RGH etc Information sourced from SAAS & SAPOL 2009
Chart1
1589
2260
294300
9430
SAAS
SAPOL
Hospital Emergency Departments
Number of ED Presentations
Apr 08 - Mar 09
Sheet1
SAASSAPOL
RAH1589
FMC2260
QEH294300
*OTHER9430
SAASSAPOL
RAH1349
QEH228272
OTHERS9328
Sheet2
Sheet3
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*Total costs of bringing 594 MH patients to the ED TQEH
only..Transport Fees = $334,422.00 TQEH ED Fees= $481,734.00
=$816,156.00(Costs for all 1,111 Western MH clients approx = $1.5
million)
Remember (ACIS ERT involvement included above was only 3.5%= 36
clients for April 08 Mar 09)
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*Cost Savings AimsReduce:MH patient transportation by SAPOL /
SAAS to hospital Emergency DepartmentsMH client ED presentations
involving ERTOn hold and triage referral time when ringing MHTCost
(e.g. stress & trauma) to consumer and carerIncrease:Referrals
to MHTS (131465) by SAPOL / SAAS and others.ERT participation which
may then reduce the need for SAPOL and/or SAAS involvementSAPOL
awareness/education of MH servicesCapacity for wellness to consumer
and carer
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*Types of calls received by MHTS .Emergency Triage = ~15% of
total calls received.Information sourced from CBIS Report 2009
Chart3
84231127
83737108
183133153
183528712
74029168
54233146
64427158
44630155
547221610
44725159
445221613
351201412
55022158
549221410
452181412
454171411
45022159
45320149
44725159
64823158
45717148
357161212
Assessment
Care & Treatment
Education
Emergency Triage
Other
Sheet1
WACIS ERT VISITS 2008 - 2009
JUL 08AUG 08SEP 08OCT 08NOV 08DEC 08JAN 09FEB 09MAR 09APR 09MAY
09JUN 09
ERT Emergency Assessments91268411553478
ERT Clients Taken to ED464323231251
ERT - SAPOL Involvement253113230130
Sheet1
0
0
0
0
0
0
0
0
0
0
0
0
ERT Emergency Assessments
ERT Emergency Assessments
Sheet2
0
0
0
0
0
0
0
0
0
0
0
0
ERT Clients Taken to ED
ERT Clients Taken to ED
Sheet3
0
0
0
0
0
0
0
0
0
0
0
0
ERT - SAPOL Involvement
ERT Emergency AssessmentsERT - Taken to EDERT - SAPOL
involvement
Jul-08942
Aug-081265
Sep-08643
Oct-08831
Nov-08421
Dec-081133
Jan-09522
Feb-09533
Mar-09310
Apr-09421
May-09753
Jun-09810
000
000
000
000
000
000
000
000
000
000
000
000
ERT Emergency Assessments
ERT - Taken to ED
ERT - SAPOL involvement
Number of ERT Visits
AssessmentCare & TreatmentEducationEmergency TriageOther
Aug-0784231127100
Sep-0783737108100
Oct-07183133153100
Nov-07183528712100
Dec-0774029168100
Jan-0854233146100
Feb-0864427158100
Mar-0844630155100
Apr-08547221610100
May-0844725159100
Jun-08445221613100
Jul-08351201412100
Aug-0855022158100
Sep-08549221410100
Oct-08452181412100
Nov-08454171411100
Dec-0845022159100
Jan-0945320149100
Feb-0944725159100
Mar-0964823158100
Apr-0945717148100
May-09357161212100
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
00000
Assessment
Care & Treatment
Education
Emergency Triage
Other
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*SAAS Issues Other GPs etc Communication Problems MH Triage
IssuesAbandoned calls at MHTMHS Response time too longMHT tell cl
to go to TQEH not call CRTMHT calling SAAS/SAPOL without tasking
MHS teamsACIS availability Takes too long to give info to MHTSlow
response time from SAAS from SAPOL / MHS.Timeliness of responseACIS
receiving minimal ERT requestsPurpose of MOUsPolice
PrisonersBenchmarks 60 min MOU not working with MHTMHS
IssuesSAAS/SAPOL being held up at site while MHS interview ED
Issues Clients under arrest SAPOL should remain?SAPOL have limited
knowledge & should not be expected to get involved in
protracted mgt.ACIS Response timeInfo accessCalled in case ofBed
availability Causes PrioritisingSAPOL/SAAS to contact ED prior to
arrival.Easier & quicker to go straight to
EDJuvenilesComorbidityOHS&W TrainingMHS.SAPOL policy knowledge
will provide marketing re MHT etcSent out to jobs blindWhat is
SAPOL role in relation to Mental Health? ACIS mgt of Detn Orders
expect police will act in every caseAssess over phone prior to our
arrivalForensic Lack of meds & knowledge.SAAS delays due to
medical priorities Police then have to transport.Job
Stacking-PrioritisingJNH/RAH arrangements allegedly made when
patrols arrive nothing organised.Police Forensic MH no access to
this info.Educate to limit ED presentationsDispute Resolution re
MOUAgency staff in ED unfamiliar with MOUIssue of immediate risk
for SAPOL attendance.Why delay to await services to scene when MOU
provides for 30 min turnaround? SAPOL IssuesPatrols have no phones
to relay infotoo hardMHS info avail for SAPOL?Cause and Effect
DiagramResponse/referral times too long
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*Pareto Chart80%* 2nd survey shows Lack of available clinical
staff, leading to a slow response time as being paramount according
to the majority of respondents.
Chart1
120.12
110.23
110.34
110.45
80.53
80.61
60.67
60.73
40.77
30.8
30.83
30.86
30.89
20.91
20.93
20.95
10.96
10.97
10.98
10.99
11
&A
Page &P
Number of Votes
Accumulative %age
Sheet1
Voting ItemNumber of Votes%ageAccumulative %age
* Slow response time from MHT1212%12%
Poor Knowledge of MHS1111%23%
ACIS availability hours of operation1111%34%
MHT to advise of Risk to client, self, others1111%45%
SAAS/SAPOL held up on-site88%53%
Lack of availability of frontline therapeutic response88%61%
SAPOL roles and knowledge of MHS66%67%
No contact with NGO's66%73%
* Identify problems over the phone prior to arrival44%77%
No ACIS involvement33%80%
Forensic issues / legality33%83%
Carers want help from MHS not SAPOL33%86%
Police don't understand MH issues33%89%
No overnight MH nurse22%91%
Lack of availability of medical staff (volume pt's in
ED)22%93%
Mental illness seen as health not SAPOL22%95%
Knowledge11%96%
Narrow pathway11%97%
Difficult to access guards11%98%
Time11%99%
Pathways11%100%
Total Votes71
Sheet2
Sheet3
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*PDSA 1
Plan - To increase frontline therapeutic intervention at MHTS
with SAAS to reduce attendances at ED with MHTS being advised
within 24 hours Co-locate MHTS clinician onsite at SAAS. SAAS have
set guidelines for referring calls to MHTS. DO - Started 24/7/2009.
One MH Clinician who sits at 000 Facility with the SAAS call taker
to take Mental Health Referrals. STUDY the dataTest data to date
shows improvement. Data to date (approx mid point) shows an
improvement on over 50% (89 calls taken 49 ambulances cancelled).
Continue for a Month (till end of 0809)Can this be implemented on a
larger scale - Yes?ACTEnd of Month (0809) results shows 115 MHS
calls to 000. Recommend intervention to be ongoing.
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*PDSA 2Plan - To have obtained a new dedicated Hotline number
for SAPOL/SAAS to call and bypass the 131465 starting 1/10/2009Do
New mobile phone number has been provided (as above) to MHTS for
use An Intake form (Hotline Intake Referral Form H.I.R.F.1) for
MHTS clinicians has been developed due for trial 1/10/2009 in
consultation with SAPOL/SAAS for 3/12 A one page Fax form for SAPOL
to fax directly to MHTS has been developed in consultation with
SAAS/SAPOL and approved-due for trial 1/10/2009 for 3/12VPN -
Wireless laptop link approved awaiting delivery of equipment for
trial 1/10/2009 for WACIS team (ERT) Study Results pending 3/12
trial from Oct 2009
ACT Beginning 1st Oct 2009
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*CPI SA08 OUTCOMES (up to and including August) 2009 That the
client / carer will receive appropriate MH Services intervention
rather than mainly SAPOL/SAAS. Reduction of SAAS attendances to MH
clients for August 2009:Out of 115 calls 59 Ambulances were
cancelled or not required for MH clientsThis is a 51.3% Reduction
of SAAS Attendances to MHS clients and possible ED admissionsCost
Saving for the Trial is approx. $47,850.00 in one month of
trialCost efficiencies leading to smart use of this money for other
areas in MHSSeamless reporting structure Redesigning and improving
communication between SAPOL, SAAS and MHSReducing SAPOL/SAAS
transportation to ED with MH intervention within 24 hoursDecrease
SAAS/SAPOL involvement and increasing MH involvement within 24
hoursIncreasing opportunity for MHS Early Intervention / Treatment
Conclusion.. There is a direct correlation between the poor
communication from SAPOL/SAAS/MHTS resulting in costly service
inefficiencies that directly impacts on the consumer. This CPI
recommends that the current trials be implemented Statewide and
should be evaluated within the next six months.
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*Progressive Final Pilot Project Report from August 2009 to
March 2010Graph following shows the final statistics that have
resulted from the undertaken Project..
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*Final Report Summary of Pilot Project CPISA08
2009-2010Statistics - MH Clinician in SAAS Emergency Operations
Centre
Month No of Calls No of Ambulances % Taken NOT required August
2009 115 59 51.3%September 200998 45 45.9%October 2009
602948.3%November 2009643148.4%December 2009623556.5%January
2010794848.1%February 2010 723954.2%March 2010492653.1%
59931252.1%
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*Emergency Operations Centre (SAAS).The following bar Graph
shows. the number of calls taken by a mental health clinician at
the Emergency Operations Centre (NB stats gathered were taken
during ONE - 8 hour shift only per day) versus the number of
ambulances tasked from the Emergency Operations Centre (SAAS)Then,
shows the percentages of Ambulances diverted by MHTS clinicians at
the 000 call centre.
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*Statistics - MH Clinician in SAAS Emergency Operations Centre
cont
Chart1
1155951.3
984545.9
602948.3
643148.4
623556.5
794848.1
723954.2
492653.1
No. of calls taken
Amb. Not Required
Percent
Sheet1
Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10Feb-10Mar-10
No. of calls taken11598606462797249
Amb. Not Required5945293135483926
Percent51.345.948.348.456.548.154.253.1
Sheet1
000
000
000
000
000
000
000
000
No. of calls taken
Amb. Not Required
Percent
Sheet2
Sheet3
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*Interpretation The graph show a tapering trend downwards in
demand of callers using the service with having a Mental Health
clinician attached to the SAAS-EOC. Why is this happening? 000
Calls made to the EOC have been identified to be known clients and
/or frequent callers over-utilising this emergency service rather
than calling the 131465 MHTS
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*Statistics and Cost Savings from this Project for
SAAS/MHTSResults - In saving 312 ambulances from attending a scene,
using the current costing model of an average transport cost at
$811 savings made from August 2009 to end of March 2010 equates to
$253,032
Assumption larger cost savings could have been made if the SAAS
000 criteria was expanded and referred to MHTS clinicians to
further triage these calls.
Moreover there could also be more of a coordinated partnership
model to be further developed between SAAS and MHTS. This should
improve costs reductions and result in a more focussed clinical
intervention program to identify MH clients needs sooner.
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*SAPOL Referral(s) Outcomes- ERT and Non-Urgent -The following
slide/stats shows the period of Dec 09 March 2010.The number of
evidenced referrals from SAPOL to MHTS was under estimate as was
ERT taskings/referralsThat Western ACIS was only involved in only
3.5% of all presentations see slide 8No figures are available for
costings from SAPOL regarding transport to and from EDs (with ERTs
and non Urgent presentations).Referrals to MHTS Hotline were not
used. Stats available refer to faxed referrals for non-urgent
clientsFurthermore It appears that SAPOL continue to bypass MHTS
referrals and transport MH clients directly to ED TQEH etc.
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*Non-Urgent Referrals from SAPOL to MHTS using new referral
processCommencing 1st Dec 2009Dec 7 referrals (6 referred to
Community MHS 1 No Follow Up Required)Jan 2 referrals (both
referred to Community MHS)Feb 7 referrals (6 referred to Community
MHS 1 No Follow Up Required)Mar 2 referrals ( 1 referred to
Community MHS 1 No Follow Up Required)Note: Between 15.12.09
08.02.10 = 68 & between 9.02.10 6.04.10 = 44 clients were taken
directly to TQEH ED by SAPOL
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*Emergency Response Team Mental Health (ERT)From Aug 2009 Mar
2010 there were 42 ERT attendances out of which 15 ERT clients were
taken to TQEH-ED.From these figures it is indicative that the
service provided by ERT is under utilised by Emergency Services a
possible reason for the very low referral numbers are that the
calls made to the direct 24 hour mobile phone hotline at MHTS (as
per pilot project initiative) are possibly due to the lack of
knowledge about the improved referral communication pathwaysCurrent
practices of taking mental health clients to the ED directly still
continue. This practice may be viewed as the quickest way for
emergency services to expedite the conveyance of clients to the
ED.A further hypothesis for the low referral to MHTS may also
include certain historical work practices that are culturally
ingrained within the emergency services organisation(s)That there
could be a lack of awareness of the seamless and improved direct
referral pathways to MHTS for referring emergency services This is
an area which will need further education and development between
SA Emergency Services and the MHTS in the future.
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*Recommendations SuggestedWith the Review of the Memorandum of
Understanding between MH services, Police and Ambulance currently
in progress in 2010 the findings of this project provide essential
information for future service planning. The evidence in this CPI
project provides and opportunity here to incorporate this model
statewide within the current MOU review.More educational sessions
are needed to update Police and Ambulance about utilising /
accessing Mental Health Triage Service (MHTS) more
efficiently.Management from all services need to undertake and
incorporate the reforms suggested in this CPI project as statistics
(and cost savings) can be improved overall. This will better
provide a more comprehensive and responsive service to our MH
consumers within South Australia.
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*ENDInformation contained in this CPI Project presentation was
researched, compiled and collated by Ernie Sorgini and Michael
Bailie CNAHS - Western ACIS 2009-2010
*