SWSLHD and Bowral's Health - 41

Mental health nurses improve access

• By Gemma Collins on  24 October 2011 - 6Minutes

Incorporating mental health nurses into general practice can lead to better outcomes for patients and GPs, but a shortage of these specialist nurses could make it difficult to expand the program, a pilot scheme has found.

A four-year program, which involved mental health nurses working with GPs and private psychiatrists in five states, was found to have “significantly improved” access to appropriate mental health services, a report has revealed (link).

More than 40,500 people received a service through the $191.6m Mental Health Nurse Incentive Program (MHNIP) from 2007-2011, in a range of areas which ranged from one nurse supporting one practice to seven nurses supporting 29 practices, according to the recently released report.

The authors say the program led to earlier intervention, shorter admissions and better follow-up with patients receiving mental health services in “convenient and non-stigmatising settings”.

GPs said they felt better supported in their work with mentally ill patients and said their knowledge and confidence had improved. 

Out of the 57 patients who were surveyed, 80% reported improvements in their mental health and almost half reported improvements in their social relationships. 

The government has since announced it will allocate a further $13m over two years to employ an additional 136 mental health nurses.     

But the limited availability of ‘credentialed’ nurses, particularly in rural areas, could make it difficult for the program to expand, the authors say.  

The funding which was based around a fixed payment per half day session was also found to be a deterrent, as it did not allow for any additional costs including computers or professional development and for the extra time needed to get around rural areas.

Now here is an interesting tale! I'm told that the Southern Highlands still has only one Credentialed Mental Health Nurse who provides this service. Other's have tried to enter the SH area to also provide the service but have not been supported by .... you guessed it !... the CEO of the Southern Highlands Division of General Practice..... who suggests it may be due instead to the others not being able to market themselves to the GPs. I guess it does not help if the CEO informs the GPs who are interested that they would be more open to being audited and other bits of misinformation guaranteed to turn off even the most ardent advocate for the program. The fact remains that since the failure of their own staff member in achieving credentialed mental health nurse status, the Southern Highlands Division of General Practice has taken their bat and ball and left the MHNIP field of play.

The Southern Highlands Division of General Practice and the disappearing Mental Health Nurse Incentive Program

Socrates has become aware of the fact that the Southern Highlands Division of General Practice appears to have changed is view on the value of the Mental Health Nurse Incentive Program (MHNIP) which is a Medicare Australia funded program designed to help persons with a severe mental illness receive the care coordination that would allow them to remain at home and out of hospital. It would seem to any reasonable person that this would be a useful initiative for the person with the mental illness, their carers or family members, and for the hospital services.

The MHNIP operates from general practitioners, general practices, private psychiatrists, Divisions of General Practice and from Aboriginal Medical Services who have registered with Medicare Australia as an "eligible organisation". The registration is simple enough and the Medicare Australia will even offer financial incentives to the "eligible organisations" to establish the MHNIP in the community.

Now, in Australia there are about 800 credentialed mental health nurses (CMHNs) able to to provide these services to patients through the "eligible organisations". Fortunately, as Socrates has discovered, there are 3 qualified CMHNs in the Southern Highlands, yet only one is being used by any of the eligible organisations here to provide any sort of service to patients of the practices in the Southern Highlands. Perhaps it's just a coincidence that the one CMHN being used was once an employee of the Southern Highlands Division of General Practice. Socrates, has recently discovered that patients who have been referred to that one CMHN have been told by them that they are unable to provide any additional people with the MHNIP services. Obviously (or hopefully), that information has been passed on to the Southern Highlands Division of General Practice so that they can pass that information on to their members.

Perhaps it is also a coincidence only, that the Southern Highlands Division of General Practice in 2008-09 employed a mental health nurse/psychologist to provide the MHNIP services to their member general practitioners. The aspiring nurse, who was seeking credentialing, was unable to obtain this requisite by the January 2010 deadline so the Southern Highlands Division of General Practice was unable to continue the MHNIP program. However, it would seem that they did continue to employ the nurse because they were also a psychologist and now they offer a "Better Access" counselling service in competition to those psychologists and social workers in private practice.

Now, as far as Socrates is aware, the Southern Highlands Division of General Practice is still an "eligible organisation" or could easily become one again. However, the Division has made no attempt to engage or contract the other CMHNs in the Southern Highlands nor does it appear to have been advocating to their general practice members that they take up this initiative for the benefit of their patients. One could easily draw a conclusion that the Southern Highlands Division of General Practice is taking the view that if they can't retain or employ a CMHN of their choice, then no-one else should be able.

Strangely, any recent information about the MHNIP which was originally publicly provided by the Southern Highlands Division of General Practice to all, through their "Highlands Doctor" newsletter on their website, was suddenly transferred to the login section of their website for member GPs only. One can only deduce what the general practitioners are being told by the Division's Executive Officer.

Socrates has been told of one patient who is seeking access to the MHNIP because they have a number of severe mental health conditions that they have been unable to get any sense out of the Southern Highlands Division of General Practice. It is most likely that there are many such people who have been struggling with a severe mental illness but are now being denied a potentially excellent service. Socrates has noted that the Network which advocates for Divisions of General Practice is very supportive of the MHNIP initiative and there is ample proof that it is a win-win situation for all.

So the question needs to be asked: Why does the Southern Highlands Division of General Practice not advocate with its members to implement this Medicare funded initiative for patients with severe mental illnesses? Surely, the Southern Highlands has it's share of people afflicted with such mental illnesses? Why does the Southern Highlands Division of General Practice not use its "eligible organisation" status to employ, contract or retain our other CMHNs? And what was so secret about the Division's advice to its general practice members that they felt the need to place that information in the login section of their website. If it is simply the same information that they have freely published in their past issues of the "Highlands Doctor" newsletter why was there a need to place the information in their website which is not accessible to members of the public.

Socrates has previously commented on the MHNIP as an ideal initiative for persons with mental illness and for their carers. Perhaps it is now time for those members of the public to challenge the secretive behaviour of the Southern Highlands Division of General Practice and its Executive.

Southern Highlands Division of General Practice - working collaboratively or competitively?

Socrates has said this before, that there is a whiff of smoke coming from the offices of the local Division of General Practice (or is it the smell of bull dung?)

From the Athenian network have come some recent gems of the non-wisdom of the Division's illustrious leader! Take this one, for example, where a local private allied health professional suggested greater collaboration between the private practitioners and the public health system and the local Division in order to improve the health outcomes of their patients, and increase their access to allied health services. The letter was written on 15th February 2010 just after a meeting, sponsored by the Southern Highlands Division of General Practice, with some public health service nursing staff and allied health professionals and perhaps 2-3 general practitioners and their practice nurses. Not many when you consider that there are 18 practices with some 72 general practitioners in the Southern Highlands.

"Dear Dr Ruscoe,

RE: Live Life Well presentation

Thank you for the opportunity to attend the presentation by LD last Thursday. I found it informative, and a useful forum to make contact with other health service providers, many of whom I knew from my previous work within the area health service.

What was perhaps very disappointing was that, with the topic being the connection between chronic medical conditions and mental illness, there was little representation from general practitioners and none at all from the SSWAHS mental health services.

When one speaks of communication between the various health service providers one does usually mean between all health service providers, those in the private and the public health sectors.

It puzzles me that the general practitioners and the local mental health services are now not as responsive to these gatherings and presentations to enable improved utilisation of the health service initiatives available to their patients.

I would be interested to know how an improvement in the liaison and collaboration between all health service providers could be achieved in the future. Perhaps you and the Division have some ideas how this could be achieved.

I intend to discuss with other psychologists the concerns that I have expressed above, that there is a need to find an improved way of developing the communication between all service providers. This may involve better use of telephony (phone, email or fax), or discussion with the Division’s general practitioners as to the way in which they would prefer contact by other allied health workers.

Additionally, I suggest that communication is a two-way process otherwise it is just information. If the Division and the general practitioners have any thoughts about how we allied health professions can improve our process of communication I would be pleased to hear from you or any of the general practitioners.

I might add that I have attempted recently to improve the communication between allied health professionals and the local community mental health service. Unfortunately, the health service appears to be taking the view that they will not proactively encourage their patients to seek appropriate and available help with their long-term health and support needs in the community and private sector. They cite, instead, the NSW Health Code of Conduct which, suggests that they provide a list of local health service providers to a patient who requests it. It is disappointing to discover that the Bowral service do not actively seek to inform their patients of the availability of Medicare funded private mental health services through the Better Access and the MHNIP programs.

I would be pleased to have the opportunity to be able to discuss with the Division and the general practitioners how the private allied health professionals could improve the mental health services they are able to provide to the patients attending their practices. I would be open to any suggestions you might be able make about how this could be achieved.

Yours sincerely,

Kevin O’Neill

Psychologist and Credentialed Mental Health Nurse"

Sadly, the author of this letter sent in February is still awaiting a response to this suggestion that better communication be sought between the private health sector, the public health sector, and the Division of General Practice.

Not to be seen as a unassertive person Mr O'Neill has also provided old Socrates with some additional tablets of writing which may shine a (bright) light upon the workings of the Southern Highlands Division of General Practice and their idea of collaboration.

"Dear Dr Ruscoe,

RE: MHNIP referrals to the Division

I note that in meeting with TK at the MHPN meeting last week that she is no longer pursuing her application to become a Credentialed Mental Health Nurse for the purpose of the Care Coordination role of suitable patients of the general practitioner members of the Division.

Given this current situation I am wondering if the Division would consider informing the general practitioners and the various practices of this change. I believe that this would enable some practitioners, and their practice groups, not already linked with AT to have the additional choice of retaining the two remaining Credentialed Mental Health Nurses in the Southern Highlands.

I would be most happy to discuss how this might be achieved, with individual general practitioners or their practice managers, at their convenience.

In any anticipated discussion the mutual benefit of the practices gaining a financial outcome from Medicare Australia and the added advantage of appropriate care coordination for their referred patients will be an issue to be discussed.

I note that there is possibly due to be an issue of the Highlands Doctor going out to the practices soon. Might I ask that this information be included in the pending Highlands Doctor issue, or by some other means to your Division’s members.

I look forward to your response.

Yours sincerely,

Kevin O’Neill

Psychologist and Credentialed Mental Health Nurse"

Now for the response on July 14th - if it can be called that!

"Dear Kevin,

Thank you for your letter of June 29 in regard to services under the Mental Health Nurse Incentive Program.

Please be assured that we have thoroughly researched the procedures with the Department of Health for the implementation of this program in our practices and that the appropriate advice has been provided to practices.

Yours faithfully,

Warwick Ruscoe"

Well, of course that led to some headscratching on the part of the recipient but, not to be overwhelmed by the vagueness of it all, he did persist. Following his own questions to the Australian College of Mental Health Nurses, who credential the nurses working in the Mental Health Nurse Incentive Program, and who, one would expect, would know all there is to know about how general practitioners can use the Credentialed Mental Health Nurse, it would appear that there had not been any change in the contracting or employment of the qualified nurse by general practitioners. So off went a follow-up letter to the local Division of General Practice.

"Dr Warwick Ruscoe

Southern Highlands Division of General Practice

PO Box 724Bowral NSW 2576

11 August 2010

Dear Dr Ruscoe,

Thanks for your response of 14 July in which you responded to my earlier letter in which I asked about whether General Practitioners would be advised of the availability of the MHNIP services in light of your employed staff member not attaining her credentialing from the Australian College of Mental Health Nurses (ACMHN).

I did ask whether the general practitioners would be advised through the Division’s “Highlands Doctor” that there were other options available should they wished to refer their patient to another credentialed mental health nurse.

Unfortunately, your response of 14 July does not inform me of what your research and discussions with the Department of Health referred to, in respect of the implementation of the MHNIP in the Division's practices, nor was there any indication what the advice might have been that was provided to practices.

Today I received a response from the CEO of the ACMHN who has advised me that there has been no change to the MHNIP by Medicare Australia and that eligible organisations may continue to employ, or engage a Credentialed Mental Health Nurse to carry out the roles described in the program documentation. This means that GPs or Practices which are, or may wish to become, eligible organisations (EO) may employ them or engage them, by way of an agreement between the CMHN and the EO, to provide the service. The engaged or contracted CMHN is required to have adequate PII and registration to assure the EO that they can provide the service adequately to the doctor’s referred patients. The engaged CMHNs are not required to work on-site at the EO but can work from a private practice or even from home.

I would appreciate having access to the information about MHNIP provided by the Division recently to its practices.

Yours sincerely,

Kevin O’Neill

Psychologist andCredentialed Mental Health Nurse"

And here, of course, is the local Division's final word!

"August 18, 2010

Dear Kevin,

Thank you for your latest letter of August 11 in regard to the services under the Mental Health Nurse Incentive Program.

As previously stated, we have informed member practices of the Health Department's guidelines and rules for the engagement by practices of credentialed mental health nurses, either as contractors or employees. Should you wish to offer services in this regard, that is a matter between the practices and yourself.

It is not our policy however to inform outside parties of our communications to our members. The above information is available through the Department of Health's website.

Lastly, I commend to you that, unless there is a change to the rules to this program, this concludes our correspondence on the matter.

Yours faithfully,

Warwick Ruscoe."

Well, that certainly shows that the exchange of wax tablets has certainly dried up! Very pesky of the psychologist to ask such pointed questions. Anyway, it's Doctor's Secret Business anyway! Or is it really? You see, until the most recent "Highlands Doctor" issue the Mental Health Nurse Incentive Program (MHNIP) was commented upon in every issue of the "Highlands Doctor" from late 2007, and the local doctors were exhorted to use the Division's own Credentialed Mental Health Nurse while she was attempting to get her credentials through the Australian College of Mental Health Nurses. After this did not happen and the Division was no longer able to use her, the MHNIP became "secret" business. Now, following the exchange of the wax tablets, Socrates has noted that the public information on this program (which could help many local people with severe mental illnesses) has suddenly been moved to the member's only Login page of the Highland's Doctor. I guess one can only speculate why a once public piece of information has now gone to "It is not our policy to inform outside parties of our communications to our members." Well, in Socrates's reading of the older editions of the "Highland's Doctor" on the Division's website he finds each edition full of the Division's "communications to our members." Especially, the current one, which publicly urges all their member general practitioners to refer their patients to the Division's employee for counselling under the Medicare "Better Access" initiative.

Hmmm! I guess the Southern Highlands Division of General Practice has to go where the money is! I wonder, what happens to the notion of the patient's of the general practitioners having a choice in who they want to see. The Division's position and involvement with the local medical practices does seem to suggest that it has a conflict of interest and, monopoly and, the Gods forbid, might be seen as part of a cartel arrangement. I wonder if the Oracles in the Department of Fair Trading, Small Business, or Medicare Australia would (or should) be concerned about this?