Local Mental Health and Addictions
Group
Summary and update for DSAC
12 June 2007 (continued in
August)
Contents
•
•
•
•
•
•
•
•
HHS Current Issues
HHS Enhancing Crisis and Acute Services
The Journey Forward
NGO Development
Services for Maori
Primary Mental Health
Information and Analysis
Acute Service Spectrum Development
HHS – Mental Health Issues
•
•
•
•
Vehicles
Electronic Health Record
Access targets
Enhanced Responsiveness Project (CATT
Review)
Targets
Actual
04/05
Actual
05/06
Forecast
06/07
Target
07/08
Target
08/09
Target
Reduced disparities in health status
09/10
MHS Utilisation by Capital & Coast residents (%)
No
All Age Groups
Maori
Pacific
Other
8,000
Total
3.1
1.2
1.9
1.9
3.1
1.3
1.8
1.9
3.7
1.9
2.0
2.2
3.9
2.4
2.2
2.4
3.9
2.4
2.2
2.4
4.2
2.6
2.3
2.5
Capital & Coast Residents
seen by Mental Health Service
6,000
4,000
No. of C&C residents seen by MHS
2,000
All Age Groups
Maori
Pacific
Other
Total
887
250
4,100
5,237
895
275
4,100
5,270
1,075
425
4,400
5,900
Long term clients with relapse prevention plan (%)
All age groups
1,150
530
4,920
6,600
1,150
530
4,920
6,600
1,235
585
5,180
7,000
95
95
95
0
04/05
05/06
Maori
06/07
07/08
Pacific
08/09
09/10
Other
Access Rates Dec 2005 - Nov 2006
4.0%
06-07
Target
3.7%
3.5%
% of Population
3.0%
2.5%
06-07
2.0%
06-07
Target
Target
2.0%
1.9%
1.5%
06-07
06-07
Target
Target
2.0%
2.2%
1.0%
0.5%
0.0%
C&Y
Maori
MHINC Contacts
Pacific
Unreported Contacts*
Other
GP Liaison*
Total
NGO*
Enhancing C&C DHBs
Crisis & Acute Mental
Health Services
Enhancing C&C DHB's Crisis &
Acute Mental Health Services
Align with
• The Journey Forward
– The Acute and Crisis Workstream
– Improving Access to Primary Health and
Mental Health Services.
• The Crisis Review Project
Enhance service response by
• Lowering threshold for accepting people for
assessment
• Increasing threshold for entry to (on-going)
case-management
• More purposeful engagement focused on
expected outcomes
• More proactive discharge planning with ease of
re - entry into the service if required
• More standardisation of processes for the
‘predictable’
• Improve access to the ‘right’ staff and services
Enhance service response by
•
Improving relapse prevention and more use of advanced
directives for those consumers who already have a
relationship with services
•
Increasing collaboration between MHS, PHOs, NGOs,
other health care services and community
organisations. Including more availability of MHS for
consultation and advice
•
Improving ability of current ‘silos’ to pool resources in
order to maximise coverage and efficiencies
A Proposed New Model
Crisis
Resolution
Assessment
Clinic
CMHT
Community
Consultation
Case Management/
key work/
other
Enhancing C&C DHB's Crisis &
Acute Mental Health Services
Access & Assessment Model 1
crisis referrals
Mental Health Line
Kapiti
Porirua
All other referrals
Wellington
South
Combined Functions
Care
Management
Crisis
Resolution
CMHT
Community
Consultation
Care
Management
CMHT
Assessment
Clinic
Community
Consultation
Access & Assessment Model 2
crisis referrals
Mental Health Line
Combined
Functions
Kapiti
Porirua
All other referrals
Wellington
South
Access & Assessment Model 3
crisis referrals
Mental Health Line
Combined
Functions
Kapiti
Porirua
All other referrals
Combined
Functions
Wellington
South
Access & Assessment Model 4
crisis referrals
Mental Health Line
Other
Some Combined Functions
Kapiti
All other referrals
Porirua
Wellington
South
Acute Resource
Coordination
APOC
ECS
EF
FPOC
Service
Coordination
Kapiti
Acute resource
Coordination 24/7
Wellington
ADS
TWOM
ADS
CR
TWOM
RH
CR
Acute resource
Coordination 24/7
RH
Porirua
South
Key areas to support for improved integration and
access/response
•
•
•
•
•
•
•
•
•
Emergency Dept & General Hospital
Maori Mental Health
Health Pasifika
Older persons
CADS
Children & Youth
RFRIDS
Consumer Run Services
Other?
Enhancing C&C DHB's Crisis &
Acute Mental Health Services
The Journey Forward
• Workforce – linking with national and
regional developments
• Addictions – workstream now being
established
• Child and Youth strategic ‘population
approach’ being agreed
Addictions Service Development
Improve the availability of and access to
quality addictions services, and strengthen
the alignment between addiction services
and services for people with mental illness
Addictions Service Matrix
Medical
Needs
Early On-set of
Dementia
Residential
Facilities
Inpatient
Detox
Social detox
Methodone
Clinic
Community
Alcohol and
Drug Team
Community
Alcohol and
Drug Team
Wet Shelter
Regional
Residential
Rehabilitation
TACT team
Wet Shelter
Counselling
Services
Longer Term
Residential
DCM Outreach
General
Practice
Information
Services
Social
Needs
Maori
• Community and Inpatient Numbers
• Te Puwaitanga Review
• Initiatives
Acute Unit Total Clients
500
457
2001-2002
2005-2006
400
330
327
300
213
200
89
100
88
38
26
0
All
Maori
Other
Pacific
Acute Unit Total Clients Percentage
80%
72%
2001-2002
65%
70%
2005-2006
60%
50%
40%
27%
30%
19%
20%
8%
10%
8%
0%
Maori
Other
Pacific
14000
12000
Acute Unit Total Bed Nights
13281
2001-2002
2005-2006
10791
9450
10000
8000
6398
6000
3530
4000
2456
1375
2000
863
0
All
Maori
Other
Pacific
Acute Unit Total Bed Nights Percentage
80%
71%
2001-2002
70%
2005-2006
59%
60%
50%
40%
33%
30%
20%
18%
10%
10%
8%
0%
Maori
Other
Pacific
Acute Unit Total ICU Bed Nights
4000
3647
2001-2002
3500
3000
2005-2006
2900
2515
2500
2000
1611
1500
1112
1000
711
421
500
177
0
All
Maori
Other
Pacific
Acute Unit Total ICU Bed Nights Percentage
80%
2001-2002
69%
70%
2005-2006
56%
60%
50%
38%
40%
30%
19%
20%
12%
6%
10%
0%
Maori
Other
Pacific
Acute Unit % of Total Clients with Nights in ICU
80%
72%
70%
60%
58%
59%
2001-2002
63% 2005-2006
62%
57%
55%
46%
50%
40%
30%
20%
10%
0%
All
Maori
Other
Pacific
Acute Unit Avg Total Nights Per Client
45
2001-2002
40
40
36
33
35
30
29
2005-2006
33
28
29
30
25
20
15
10
5
0
All
Maori
Other
Pacific
Acute Unit Avg ICU Nights Per Client
14
13
2001-2002
12
11
10
2005-2006
9
8
8
8
8
8
7
6
4
2
0
All
Maori
Other
Pacific
Acute Unit Readmission Rate (< 30 days)
18%
16%
14%
2001-2002
2005-2006
17%
16%
15%
15%
12%
12%
11%
11%
10%
7%
8%
6%
4%
2%
0%
Total
Maori
Other
Pacific
Total Community Treatment Days June 2004 - Oct 2006
120000
100000
97124
80000
56001
60000
40000
20400
20000
14807
5916
0
Total Community
Days
Community
Acute Days
TransCultural
Days
CMHT Days
TACT Days
All Unique Clients Seen in Community June 2004 - Oct
2006
6%
n = 5272
19%
Maori
Other
Pacific
75%
All Community Treatment Days June 2004 - Oct 2006
7%
20%
n = 97124
Maori
Other
Pacific
73%
Community Acute Treatment Days June 2004 - Oct 2006
5%
n = 20400
17%
Maori
Other
Pacific
78%
Transcultural Services Treatment Days June 2004 - Oct
2006
n = 14807
20%
2%
Maori
Other
Pacific
78%
Adult CMHT Treatment Days June 2004 - Oct 2006
4%
5%
n = 56001
Maori
Other
Pacific
91%
TACT Treatment Days June 2004 - Oct 2006
4%
n = 5961
24%
Maori
Other
Pacific
72%
Te Puawaitanga Goals
•
Goal 1: Provide comprehensive clinical, cultural and support services to at least 3
percent of Maori, focused on those who have the greatest Mental Health needs
•
Goal 2: Ensure that active participation by Maori in the planning and delivery of
Mental Health services reflects Mäori models of health and Mäori measures of
Mental Health outcomes
•
Goal 3: Ensure that 50 percent of Maori adult Tangata Whaiora will have a choice
of a mainstream or a Kaupapa Maori community Mental Health service
•
Goal 4: Increase the number of Maori Mental Health workers (including clinicians)
by 50 percent over 1998 baselines
•
Goal 5: Maximise opportunities for intra and intersectoral co-operation
Areas for Further Development by DHB
3
Score out of 5
2.5
HB
Midcent
Wanganui
Wairarapa
Hutt Val
C&C
2
1.5
1
0.5
0
G1
G2
G3
G4
Te Puawaitanga goals
G5
Maori Initiatives (update)
• Matatini (4 place Recovery House)
• Te Upoko Nga Oranga o te Rae (regional
development service)
• Maori Consumer Consultant (HHS services)
Primary Care Initiatives
• Existing GP Liaison Scheme
• MoH Pilots
Needs of the Population
Acute ‘care and protection’
CMHT
NGO’s
Long term support for high and
complex needs
Primary Care
Prevention and
Promotion in
Communities
Funding Paradox
Services
Funding
Assumptions
• Mental health problems for individuals will generally get worse if left
untreated
• Major mental health problems don’t just occur out of the blue/occur
overnight – they build up over time
• Most people, if given good information for self management, can take steps
to remain more mentally healthy than if they are uninformed or subject to
internalized stigma
• Many people who live in difficult social circumstances will experience
these as a negative impact on mental health - therefore an improvement in
social circumstances will generally mean an improvement in mental health
Current Access Inertia
Acute
CMHT’s
NGO’s
Primary Care
Prevention and Promotion
High Level Process map – stepped approach to care
Acute
Recovery / Long Term
Primary Care
Prevention
Targeted
Prevention and
Promotion and
Social Supports
Resources
Managing the
Effects of
institutionalisation,
stigma and
delayed support
and services
Time
The Way We Organise Services
?
Primary Care
NGO’s
CCDHB / MHS
The way we should integrate services
Access
Barriers
Primary
Care
CCMHS
NGO’s
Increasing Behavioural Needs
People with high
behavioural and low
social needs
People with high
behavioural and high
social needs
People with low
behavioural and low
social needs
People with low
behavioural and high
social needs
Increasing Social Needs
Increasing Behavioural Needs
Specialist Clinical
Services
Primary Care
Coordination
NGO’s
Self Help
Increasing Social Needs
Hypothetical Progression of mental illness if left untreated
Identify risk factors to help the 'continues to worsen' group first
12
Increasing Severity
10
8
Continues to worsen
Ongoing problems
6
Improves with resilience
4
2
0
1
2
3
4
5
Time
6
7
8
9
10
Information and Analysis
•
•
•
•
NGO data project
PRIMHED
Senior Analyst Position
System Reorientation
NGO Data
Table 1: Referrals for support needs assessments 01 July 2006 to 31 May 2007
Referral Source
Inpatient
Community
Number of
referrals
Purehurehu
Rangatahi
Rangipapa
Tane Mahuta
Tawhirimatea
TWOM
A&D
CATT
EIS
Forensic
GPLS
HBT
Health Pasifika
Kapiti
Porirua
PPS
South
TACT
Te Whare Marie
Wellington
YSS
TOTAL
Source: C&CDHB Service Coordination
10
7
6
6
1
43
1
1
8
2
5
1
2
9
10
1
15
6
8
35
3
180
Outcome
None declined
NGO Data
Table 1: Community residential occupancy as at 30 May 2007
Level
TLA
Current
Vacant
Funded
2
Kapiti
8
-
8
Kapiti
27
-
27
Porirua
55
-
55
Wellington
67
8
75
3/4
Source: C&CDHB Service Coordination
NGO Data
Table 1: Community residential occupancy by ethnicity as at 30 May 2007
Level
2
3/4
Total
Maori
Male
Female
21
21
12
12
Source: C&CDHB Service Coordination
Pacific
Male
Female
10
10
1
1
Male
6
68
74
Other
Female
2
37
39
Total
Male
Female
6
2
99
50
105
52
NGO Data
Table 8: Support in the Community Service as at 31 May 2007
Wellington
Pathways Trust
Porirua
98
Kapiti
Total
-
98
Qnique
35
1
-
36
Wellink Trust
71
26
17
114
Wesley Care
13
Pathways Enhanced Community Support Service = 41
13
NGO Data Project Purpose
Promote effective integrated care and support for
mental health service users by:
• Increasing the information available for NGO providers to
better manage their business and help them develop a
culture of continuous quality improvement.
• Enhancing coordinated health care and service
integration between NGO and DHB clinical services so
that each party is aware of the others contribution to the
process of recovery by the service user.
• Enabling Funding and Planning to monitor and evaluate
service performance and to have better information to
inform service planning.
NGO Data Project
The goal of the project is to develop a
mechanism for the effective reporting of good
quality information about the utilisation of
mental health NGO services by consumers.
Counties Manukau DHB
CLS - an example of information use by NGOs
Counties
Manukau DHB
Capital & Coast
DHB
Hutt Valley DHB
440,600
272,400
139,000
% Maori
17%
10.5%
17%
% Pacific
21%
8%
8%
10
29
11
Total population
No. of MH NGO
providers
Sources: DHB DAPs for 2006/07 and the NGO-IT report (2006)
Community Living Services (CLS)
• Community Living Services (CLS) were established in
CMDHB in 2004 in response to a shortage of individualised
community living options.
• Six NGO providers work in close partnership with a CMDHB
clinical team.
• CLS emphasises a strength based and person-centred recovery
orientation.
• CLS service specification includes information that providers
report on a monthly basis to the DHB.
• Routine data is used as the basis for generating regular
provider reports and for the purposes of evaluating CLS.
Counties Manukau DHB
CLS evaluation
Summarised quantitative reports
CLS Evaluation Framework
Consumer profile
Outcomes
(who used the service?)
(impact of service?)
Services
Quality
(what was done?)
(how good was it?)
Number of service users enrolled in CLS
300
250
200
150
100
50
Fe
b0
Ap 5
r- 0
Ju 5
n0
Au 5
g05
O
ct
-0
De 5
c05
Fe
b0
Ap 6
r- 0
Ju 6
n0
Au 6
g06
0
# Enrolled Last
Month End
# Registrations
# Exits
Diagnosis breakdown
Breakdown of Current High Level Diagnosis for Episodes open in the Past 12 Months
% of Clients
25%
0%
Schizophrenia / Other Psychotic
Disorder
13%
5%
Depressive Disorder
4%
Personality Disorder
Other
Anxiety Disorder/OCD/Eating
Disorder
No Diagnosis
75%
72%
Bipolar Disorder
Substance Abuse
50%
2%
2%
1%
2%
Outcomes of CLS use
Outcomes for clients served in September 2006 vs registration
For clients served in September vs Registration
Deteriorating
93%
100%
Stable
Improving
65%
34%
45% 42%
41%
32%
24%
1%
14%
6%
4%
0%
Income
Support
Housing
Location
Service User : FTE ratio
Client to FTE Ratio: 12 Month Quarterly Trend
10
8
2006
Qtr4
Qtr3
Qtr2
7
Qtr1
Client : FTE Ratio
9
% time in direct service delivery
FTE Utilisation: Direct Client Contact Time as a Percentage of Available Time for the Month:
12 Month Quarterly Trend
39%
38%
% of Available Time
37%
all services
36%
35%
Note: Available
Time calculated as
45 w ks/year * 40
hrs/w k * total FTE.
34%
33%
32%
31%
30%
29%
Qtr1
Qtr2
Qtr3
2006
Qtr4
Impact on costs of mental health services
Average monthly per person costs
$5,000.00
$4,000.00
CLS Flexif und
Cost Per Client
$252.17
$1,104.08
$730.30
$748.51
$3,000.00
$1,625.67
$98.69
$677.46
CLS FTE Cost Per
Client
Respite
Res Rehab
$2,000.00
$1,438.19
$1,000.00
DHB clinical
contact
$1,985.76
$1,024.87
$0.00
6 months pre registration
CLS Episode
Inpatient
Overall savings by service type
Detailed Cost Savings Analysis - Breakdown of Average Monthly Savings Per Client
From Before 6 Months to Episode
$1,000.00
$960.88
Average Savings ($)
$800.00
$600.00
$426.62
$400.00
$187.48
$200.00
$153.48
$0.00
Inpatient
DHB clinical contact
Res Rehab
Respite
Benchmarked
CLS Provider Reports
NB: These next graphs are based on dummy data and bear no
relation to the actual CLS provider benchmarked reports
Housing Outcomes
– example only
Housing Outcome Report for Episodes Active During the Month Change from Registration
14%
27%
30%
33%
41%
49%
44%
49%
63%
Improving
Stable
Deteriorating
% of Clients
62%
50%
32%
62%
32%
70%
42%
52%
31%
27%
19%
Red
11%
9%
6%
24%
17%
4%
Orange
Purple
Yellow
Blue
Green
Indigo
Violet
White
Inpatient Admissions
– example only
Change from 6 months
prior to past 6 months
Average Number of Bednights Per Client Per Month in a DHB Mental Health
Inpatient Facility Before and After Onset of NGO Service for All Clients with an
Episode of Care Open in the Past 12 Months
5.2
Bed Nights
Average Monthly Bed Nights
Average Bednights 6 Months Prior
Average Bednights in Past 6 Months
3.4
2.9
2.8
2.2
2.1
2.0
1.8
1.2
0.3
Yellow
Green
0.5
Orange
Violet
White
0.6
Blue
-2.3
Green
-1.7
Orange
-1.6
Violet
-1.2
White
-0.9
Blue
-2.2
Purple
-1.1
Indigo
-0.2
Red
-1.2
AVERAGE
-1.4
1.7
1.6
0.7
Yellow
1.0
0.7
0.5
Purple
Indigo
Red
FTE Utilisation
– example only
FTE Utilisation: Direct Client Contact Time as a Percentage Of Available Time for the Month:
12 Month Quarterly Trend
62%
54%
52%
52%
51%
40%
41%
45%
50%
56%
57%
45%
43%
47%
46%
47%
32%
35%
40%
Green
64%
Average for 12 mths
60%
Quarter 4
52%
49%
51%
58%
45%
47%
47%
46%
43%
Blue
33%
40%
38%
34%
% of Available Time
Quarter 3
58%
Quarter 2
59%
Quarter 1
Indigo
Orange
Purple
Red
Violet
White
Yellow
48%
Average Delay To First Contact
example only based on dummy data
Access Time: Average Days Between Date Referral Received and Date of First Contact:
12 Month Quarterly Trend
20
Quarter 3
Quarter 4
Average
12.7
10.1
12.3
8.9
4.0
6.7
0
Purple
Blue
Indigo
Orange
Violet
Yellow
Red
White
0.5
1.3
2.3
2.6
3.0
4.5
4.2
4.9
4.9
5.7
5.5
2.6
3.2
4.7
4.4
3.4
4.5
5.4
5.7
5.6
6.3
7.0
5
7.8
8.0
9.6
10.3
10
9.9
10.1
13.7
15
Average Number Of Days
Quarter 2
16.0
16.8
Quarter 1
Green
Average Duration Of Care
For Clients Exited
Average Length of Care
Average
261
243
244
251
206
Duration of Care (Days)
210
165
170
177
134
Blue
White
Red
Violet
Orange
Indigo
Green
Yellow
Purple
Acute Services Spectrum Development
• Te Whare Matairangi – numbers
• Recovery Houses
• STARS development
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Jul-06
Jun-06
May-06
Apr-06
Mar-06
Feb-06
Jan-06
Dec-05
Nov-05
Oct-05
Sep-05
Aug-05
Jul-05
Jun-05
May-05
Apr-05
Mar-05
Feb-05
Jan-05
Dec-04
Nov-04
Oct-04
Sep-04
Aug-04
Jul-04
Matairangi Occupancy Rate
130%
120%
110%
100%
90%
80%
70%
60%
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Jul-06
Jun-06
May-06
Apr-06
Mar-06
Feb-06
Jan-06
Dec-05
Nov-05
Oct-05
Sep-05
Aug-05
Jul-05
Jun-05
May-05
Apr-05
Mar-05
Feb-05
Jan-05
Dec-04
Nov-04
Oct-04
Sep-04
Aug-04
Jul-04
Matairangi Avg beds Occupied
40
35
30
25
20
Matairangi Readmission Rate
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
Readmits <30 Days
Readmits <90 Days
07q3
07q2
07q1
06q4
06q3
06q2
06q1
05q4
05q3
05q2
05q1
0.0%
A L O S b y Se r v i c e
25.00
20.00
15 . 0 0
D ays
10 . 0 0
5.00
0.00
Ser ies1
Key We way
M at at in i
Whit by House
14 . 6 3
23.59
20.22
S e r v ic e
T ot a l R e f uge e , 0 ,
0%
T ot a l Ot he r , 1 ,
N o t St a t e d , 1 , 1 %
T ot a l M a or i , 1 5 ,
1%
21%
T ot alM aor i
T ot a l P a c i f i c , 3 ,
T ot alRef ugee
4%
T ot alOt her
T ot alPacif ic
T ot alAsian
T ot a l A s i a n , 0 ,
T ot a l N Z
E ur ope a n, 5 2 ,
73%
T ot alNZ Eur opean
0%
Not St at ed
M a t a t in i, 1 8 , 2 5 %
K ey W e W ay, 2 4 ,
3 3 %
W h it b y , 3 1 , 4 2 %
The proposed acute service spectrum
Acute Service
Community
Needs/Situation
Predicted
ALOS
Places
Home Based Treatment
Works with individuals in their own home, and/or
being supported by other services
20 Days
15
Crisis respite
Used to prevent exacerbation of acute symptoms
Up to 3
days
8
Acute Service
Residential
Needs Situations
Predicted
ALOS
Places
Community Based Enhanced
Mental Health Recovery
Services
An alternative to inpatient services or support
post discharge
21 days
10 to 12
STARS
(Two services planned)
Residential Services for people requiring
significant levels of medical, nursing and
therapeutic support. Acute and planning
admissions
21 days
16 to 18
Acute Service
Inpatient
Acute Assessment Unit
Needs/Situations
For people requiring significant levels of medical
and nursing assessment and treatment
Predicted
ALOS
3-21 Days
Places
20
Why do we want to purchase a STARS
service?
• Flexibility of services as community
needs and expectations change over
the coming years
• To develop a range of recovery
orientated services inline with
objectives of The Journey Forward
Why do we want to purchase a STARS
service?
• Provide a more “home-like”
environment
• Care is provided closer to the
community for less disruption to the
persons natural support systems
Why do we want to purchase a STARS
service?
• Opportunity to further develop a
collaborative and recovery orientated
workforce
• Part of the range of solutions to reduce
the ‘bottleneck’ experienced by having
just one fixed capacity acute ward
Why purchase from an NGO?
• NGOs have wide ranging experience in
establishing and maintaining
comfortable and community based
services
• Fits with an overall strategy of
encouraging NGOs to take more
responsibility for sharing the acute end
of the service spectrum
Why purchase from an NGO?
• Allows for more flexible working
relationships and structures
• Collaboration of knowledge and
experience
Selecting an NGO Partner with
• Strong recovery values and recovery
orientated employees at all levels
• Proven ability in innovation, staff
motivation and good working
conditions
• Advanced abilities to engage and
involve consumers in service design
and delivery