mid north coast local health district mental health...

1 MENTAL HEALTH CLINICAL SERVICES PLAN 2013-2021

RICHARD GILBERT CONSULTING

Mid North Coast Local Health District

Mental Health Services Clinical Services Plan 2013 - 2021

September 2013

MENTAL HEALTH CLINICAL SERVICES PLAN 2013 - 2021

richard gilbert consulting

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TABLE OF CONTENTS

1 Executive Summary and Recommendations ........................................................................ 4

2 Background ...................................................................................................................... 13

3 Guiding Principles ............................................................................................................. 15

4 Policy and Planning Background ....................................................................................... 15

5 Service Need .................................................................................................................... 25

5.1 Mid North Coast ................................................................................................................... 25

5.2 Current and Projected Population Profile ............................................................................ 25

5.3 Epidemiological Profile ......................................................................................................... 27

5.4 Service Demand .................................................................................................................... 30

6 Current Services ................................................................................................................ 37

6.1 Mid North Coast Local Health District .................................................................................. 37

6.2 Hastings Macleay Clinical Network ...................................................................................... 39

6.3 Coffs Harbour Clinical Network ............................................................................................ 42

6.4 Non Government Services .................................................................................................... 48

6.5 Private Services ..................................................................................................................... 50

7 Current Activity ................................................................................................................ 51

7.1 Acute Inpatient Mental Health Services ............................................................................... 51

7.2 Non-Acute Mental Health Services ...................................................................................... 54

7.3 Community Mental Health Services ..................................................................................... 54

8 Current Issues in Service Delivery ...................................................................................... 56

8.1 Service Capacity to meet Current Population Demand ........................................................ 56

8.2 Population Growth and Ageing ............................................................................................ 57

8.3 Condition and/or Functionality of Infrastructure ................................................................. 58

8.4 Inter-District Networking of Services ................................................................................... 58

8.5 Models of Care ..................................................................................................................... 58

8.6 Workforce ............................................................................................................................. 61

8.7 Access to Services and Transport Issues............................................................................... 61

8.8 Services for Aboriginal Population ....................................................................................... 62

8.9 Services for Refugee Community ......................................................................................... 62



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9 Projected Demand ............................................................................................................ 63

9.1 Current Capacity measured against MH-CCP ....................................................................... 63

9.2 Projected Capacity Requirements ........................................................................................ 68

10 Future Role and Capacity Requirements .......................................................................... 70

10.1 Coffs Harbour Clinical Network .......................................................................................... 70

10.2 Hastings Macleay Clinical Network .................................................................................... 71

10.3 Future Service Requirements ............................................................................................. 72

APPENDICES

A1 Resident Demand for Inpatient Mental Health Services ....................................................... 79

A2 Resident Demand for Inpatient Mental Health Services by DRG .......................................... 80

A3a Resident Demand for Inpatient Mental Health Services by Hospital (Designated Wards) . 81

A3b Resident Demand for Inpatient Mental Health Services by Hospital (Non-Designated Wards) ........................................................................................................................................ 82



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1 EXECUTIVE SUMMARY &

RECOMMENDATIONS

INTRODUCTION The development of a Clinical Services Plan for Mid North Coast LHD Mental Health Services provides the opportunity to review population needs against current service capacity and plan for the range of acute, non-acute inpatient and ambulatory services required to meet the needs of the Mid North Coast community to 2021 and beyond. This planning process represents the first opportunity to develop a Clinical Services Plan for the newly created Mid North Coast Local Health District. The plan builds on previous planning processes for the Port Macquarie Base Hospital, Kempsey District Hospital and Coffs Harbour Health Campus and for the former North Coast Area Mental Health Service. The 2012 Mid North Coast LHD Mental Health Service Clinical Services Plan has been prepared with advice from key stakeholders including service providers and consumers, to determine the service directions and capacity requirements for the mental health service over the next five to ten years. The development of this Clinical Service Plan has drawn on:

• Consultations with local clinical staff and management in October-November, 2012; • Consultations with consumers in November, 2012; • Substantial input from key stakeholders including service providers, NGOs and

Commonwealth funded services, consumers and carers at the October Planning Workshop;

• Planning projections using modelling tools and benchmarks as endorsed by NSW Mental Health and Drug & Alcohol Office;

• Guidance and feedback provided by the Clinical Service Plan Steering Committee

The development of the 2012 MNCLHD Mental Health Clinical Services Plan presents an opportunity to use the most recent version of the Mental Health – Clinical Care and Prevention methodology for estimating population requirements for mental health services to 2021. In planning for the future role and capacity of MNCLHD Mental Health Services, there is an opportunity to develop a mental health service with facilities that support contemporary models of care, including a greater emphasis on primary, community and ambulatory care services with a multidisciplinary orientation that will excel in the provision of recovery focussed care and services which are better integrated with non-government and Commonwealth-funded mental health services for the benefit of consumers and their carers.



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It should be noted however that the plan does not identify the costs of any additional positions or services, or the source of potential future funding for new services; rather, it provides the information on which to develop costings and submissions, and to be ready to take opportunities for funding when and if they arise.

PROJECTED SERVICE REQUIREMENTS In projecting future service capacity requirements to 2021/22 on the basis of the latest population projections, the Clinical Service Plan has been informed by the use of the latest Mental Health – Clinical Care and Prevention (MH-CCP) methodology1. The Mental Health Clinical Care and Prevention (MH-CCP) methodology is the recognised tool for both comparing current mental health resources against estimated prevalence in the community, and for projecting future service requirements, in NSW. The MH-CCP model, was originally developed in 2001, and has recently been reviewed and an updated methodology provided by the Mental Health and Drug & Alcohol Office in 2012. This latest model has been used for the purpose of developing estimates and projections of prevalence rates and resource requirements for the MNCLHD Mental Health Clinical Services Plan.

In comparing current mental health inpatient bed capacity with the MH-CCP estimates (refer Table 1.1 below) there are insufficient acute beds in the Mid North Coast given that there are 42 acute adult inpatient beds (declared) and no designated beds for older persons, against a projected requirement of 53 beds in 2011, increasing to 61 beds in 2021 for the adult and older persons population. It should also be noted that the design and functionality of the 12 bed inpatient unit at Port Macquarie Base Hospital does not meet health facility guidelines criteria for a gazetted mental health inpatient unit, and as such represents a current and future clinical and corporate risk. There is a deficit in the provision of non-acute, rehabilitation beds also. The projected requirement is for 14 beds across adult and older person age groups in 2011, increasing to 17 beds in 2021. At present the Mid North Coast population share of the 20 bed North Coast Rehabilitation Unit, which has a catchment covering the Mid North Coast and Northern NSW local health districts, is 8 beds as indicated in Table 1.1 below.

1 MHDAO (2012) MH-CCP 2010



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Table 1.1 Mid North Coast LHD - Current and Projected Inpatient Bed requirements Age Group Current Bed

Numbers MH-CCP 2010

2012

2011

2016

2021

Acute Child* (0-11 years) 0 0 0 0 Adolescents (12-17)* Mid North Coast

0*

2

2

2

Adults (18-64) Mid North Coast

42**

38

39

40

Older Persons (65+) Mid North Coast

0

13

16

19

TOTAL Mid North Coast 42

53

57

61

Non-Acute Adults (18-64) Mid North Coast

8+

7

7

7


0

7

8

10

TOTAL Mid North Coast

8

14

15

17

*Child and Adolescent Beds for Mid North Coast currently provided within Lismore Base Hospital CAMHU ** Does not include 10 non-gazetted acute beds at Kempsey District Hospital. +Represents 40% of the NC Rehabilitation Unit beds. The catchment for this unit covers MNC and Northern NSW LHDs Source: NSW Health Population Projection Series 1.2009, Department of Planning & Statewide Service Development Branch, NSW Health, March 2009 & Estimated Residential Population at 30 June 2006, NSW (3235.0), Australian Bureau of Statistics, July 2007, MHDAO (2012) MH-CCP 2010

In addition to the need for enhanced inpatient bed capacity, a substantial enhancement of ambulatory mental health workforce is required to provide support or people with mental health conditions living in the community and to prevent escalation of illness and hospitalisations. The MH-CCP also provides an estimate of the level of mental health workforce required in both inpatient and ambulatory settings based on the size of the population catchment. This analysis is presented in Table 1.2 below. It indicates a sufficiency of staffing of inpatient settings in the Mid North Coast LHD with current staffing within 5% of the FTE workforce estimated by the MH-CCP on the basis of the 2011 MNC population. The major deficiency in terms of staffing is the mental health workforce operating in ambulatory community settings. The staffing levels of the acute care and extended care community mental



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health teams in the Mid North Coast are significantly below those estimated using the MH-CCP as required to provide for the needs of the population of the Mid North Coast. The current 76.8 FTE clinical staff working in ambulatory settings in MNCLHD services represents around half of the Clinical staff FTE estimated using the MH-CCP 92010). Substantial enhancement of staffing levels will have significant resource implications. There is a need, however, to address the comparative under-resourcing of ambulatory mental health capacity in MNC LHD and accordingly, a modest target should be determined for achievement in each of the Clinical Networks by 2016. Table 1.2 Current Ambulatory & Acute Inpatient Workforce and MH-CCP Estimated

Requirements, 2011

Age Group Current Workforce (FTE)

MH-CCP (100%) 2011

Ambulatory Mental Health Children (0-11 years) Mid North Coast

0

18

Adolescents (12-17 years) Mid North Coast

12.74

21

Adults Mid North Coast

59

93

Older Persons Mid North Coast

5.1

26

TOTAL AMBULATORY Mid North Coast

76.84

158.0

Acute Inpatient Mental Health* Adults Mid North Coast

102.8

69


0

25

TOTAL INPATIENT Mid North Coast

102.8

94

*Child and Adolescent Beds for Mid North Coast currently provided within Lismore Base Hospital CAMHU Source: NSW Health Population Projection Series 1.2009, Department of Planning & Statewide Service Development Branch, NSW Health, March 2009 & Estimated Residential Population at 30 June 2006, NSW (3235.0), Australian Bureau of Statistics, July 2007, MHDAO (2012) MH-CCP 2010



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CURRENT AND FUTURE ROLE The population of the Mid North Coast is projected to increase by 22% between 2006 and 2021. The population aged over 65 years is projected to increase by 69% over the same period. These demographic changes will place a substantial additional demand on mental health services within the Mid North Coast.

Over the next ten years to 2021, Mid North Coast LHD Mental Health services are expected to be managed and networked on a district-wide basis. Such networking provides the critical mass to provide for the full range of services of secondary level mental health services, both hospital inpatient and ambulatory community based services, and tertiary services such as the non-acute rehabilitation inpatient unit at Coffs Harbour Campus.

Within the LHD, the provision of Mental Health hospital and ambulatory services for the catchment population will be managed within the Clinical Networks for Hastings Macleay and Coffs Harbour.

In terms of inpatient bed capacity, the Coffs Harbour Clinical Network has a sufficient overall bed capacity to meet population requirements for the next ten years. The ageing of the population will result in an increased need for specialist mental health beds for older persons within this bed complement. The North Coast Rehabilitation Unit will continue to provide for the needs of a tertiary population catchment covering the Mid North Coast and Northern NSW LHDs for the foreseeable future. In the longer term, the MH-CCP indicates that additional non-acute inpatient beds will be needed within this broader population catchment.

The Hastings Macleay Clinical Network does not have sufficient inpatient bed capacity for mental health services. There are currently only 12 beds capable of accepting acute involuntary patients in the Network and this Unit at PMBH does not meet Health Facility Guidelines in its current design and layout. The two acute units at PMBH and Kempsey Hospital are of sub-optimal size. The optimal size for an acute adult unit for efficiency of operation and safety and quality of care is around 18-35 beds.

It is proposed that a new designated inpatient unit of 25 beds be developed at Port Macquarie Base Hospital. This inpatient unit would have 19 acute adult beds including two intensive care beds and 6 beds for older persons. The unit would be designed to accept involuntary patients.

In the meantime, given the current inadequacy of inpatient beds declared under the Mental Health Act 2007, the Mental Health Service should ensure the best use of these beds at PMBH through efficient bed management and discharge planning processes. By 2016, an additional five beds will be needed. If there is an opportunity to expand to this number over the next three years - and if the likelihood of a new 25-bed unit is not likely to be achieved within this timeframe - it should be taken in PMBH in a way that provides contiguity with Ward 1A. Such beds could fill existing gaps in the younger or older age groups. A model for the younger age



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group might consider the new ways of thinking about youth as the 12-24 age group, and the service consistency this might provide for clinical linking with NGOs such as Headspace.

As indicated in Table 1.1 there are no designated mental health beds in the MNCLHD for older persons, despite the community having one of largest concentration of older people in NSW, a population which is expected to increase by 69% between 2006 and 2021. The development of Specialist Mental Health Services for Older Persons (SMHSOPs) was identified as a high priority during the planning process. Options included developing these beds as a consolidated unit at PMBH in order to maximise efficiencies in service provision and to utilise the linkages with clinical services including acute medical and aged care services on site at the higher delineated PMBH or to take advantage of the opportunity to consolidate acute adult inpatient services at PMBH as proposed above, and to utilise the mental health unit space that would be vacated at Kempsey Hospital should that development occur.

The adult acute unit at Kempsey Hospital would, after modification, be suitable to provide an older persons mental health unit of 8-10 SMHSOPs beds. Physical modification of the existing space could also resolve the physical issues that inhibit the admission of involuntary patients. The latter option is recommended.

Of equal, if not greater, importance, is the need to enhance the staffing capacity of community mental health teams across the District. Staffing capacity in these teams has not increased over the past ten years, despite the increases in population demand, and inpatient bed capacity. There is a need to enhance ambulatory staffing FTE by at least 6-10 positions in each of the Clinical Networks. Additional staff are required in child and adolescent, adult acute and extended care and older persons teams, particularly the latter.

In developing enhanced service capacity, models of care will be reviewed, clinical services planned and workforce strategies developed for the whole of the Mid North Coast by the LHD Mental Health Service to ensure the development of an appropriately staffed, in terms of skills and sustainability, mental health service capacity. In this context, it is recognised that the MNCLHD Mental Health service is faced with constrained resources and growing pressures of demand in the community, and therefore their priority should be the provision of direct clinical care for people with severe and persistent mental illness, and work with service partners in the NGO and Commonwealth funded sector who also deliver programs for people with mental health conditions.

Special project coordination positions allocated to the former NCAHS, such as SMHSOPs and Safestart, have since been split in the division into LHDs, with the MNCLHD receiving a minority share. These functions are now amalgamated into conglomerate positions that are required to focus on a disparate range of issues, with the risk that there is a diffusion of focus for these projects.



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RECOMMENDATIONS In planning for the future mental health service needs of the Mid North Coast community to 2021, the Clinical Service Plan has developed projected population requirements and measured these against the current capacity of MNCLHD Mental Health Services. The Clinical Service Plan has been informed by recent plans and policy directions at national and State level, and feedback from local services and consumers and other key stakeholders as to the most important issues that need to be addressed in delivering mental health services that result in improved outcomes for consumers and their families and carers. In making the following recommendations it should be noted that the aim of this Clinical Service Plan has been to review estimated population requirements against current service capacity and to identify where there are significant shortfalls in available resources. Achievement of attracting these resources is dependent on funding submissions and enhancement funding provided via the Ministry of Health. Implementation of some of these recommendations is dependent on achieving additional capital and recurrent funding and this CSP will provide the basis for pursuing additional funding. In the meantime the MNC Mental Health Service will continue to make best use of available resources, particularly through processes such as the proposed review of models of care identified at Recommendation l) below. The major areas that require enhancing over the next five to ten years are as follows:

a) Enhance the capacity of community mental health teams, with a priority on enhancement of specialist mental health services for older people (SMHSOPs) and ambulatory support for consumers in program places such as HASI supported accommodation

b) The enhancement of clinical staffing as identified in the CSP should occur within the context, and be guided by, the development of a Mental Health Workforce Strategy for MNCLHD

c) There is an existing shortfall in office accommodation and interview spaces, with appropriate levels of privacy, for the community mental health staff and this needs to be addressed ahead of the significant enhancement of staffing capacity proposed in the Clinical Service Plan

d) Establish a 25 bed consolidated inpatient mental health unit for the Hastings Macleay Clinical Network at PMBH with 19 adult acute beds, including four intensive care beds, and 6 older persons acute beds

e) Establish an Older Persons Inpatient Unit at Kempsey Hospital, led by a psycho-geriatrician who will provide leadership in the provision of psycho-geriatric services across the LHD, and providing 8-10 SMHSOPs beds for the care and treatment of older people on the Mid North Coast with acute psychogeriatric disorders. These beds would be complemented by the development of acute older persons beds at PMBH, and in the longer term, potentially additional SMHSOPs beds at Coffs Harbour Campus



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f) Maintenance of the North Coast Rehabilitation Unit as a non-acute unit serving the Mid North Coast and Northern NSW LHDs with consideration of the need to develop an additional unit for this population catchment within ten years

g) In addition to the need to develop designated inpatient beds for older persons mental health, there is an important need to strengthen links with aged care services on the Mid North Coast to maximise the potential to provide integrated services for the substantial cohort of older persons on the Mid North Coast who will have a range of needs including dementia and psychogeriatric conditions that will require coordinated hospital inpatient and outpatient services and community based including residential aged care support services

h) Include in the enhancement of older persons community mental health services, the capacity to provide in-reach support to residential aged care facilities in the care and support of people with dementia and psychogeriatric conditions

i) There is a need to develop the capacity to provide consultation liaison psychiatry services in each of the three major general hospitals on the Mid North Coast

j) Expansion in telehealth links with specialist mental health services in tertiary centres, including Child and Adolescent, Psychogeriatric, forensic, eating disorders and personality disorders

k) Reintroduce the provision of ECT service at PMBH l) Establish an ongoing Consortium of Service Providers for Mid North Coast mental

health services, including MNCLHD Mental health Services, NGOs, Commonwealth funded services, Aboriginal Community Controlled Health Services and other key stakeholders, as an overarching body to oversee the development and implementation of mental health services in a collaborative partnership

m) Undertake a thorough review of models of care operating in both inpatient and ambulatory settings across the Mid North Coast, with the aim of updating these on the basis of latest evidence as to what works best for consumers including new models of care that have been implemented successfully in other locations, under the guidance of the Consortium of Service Providers.

n) Enhancement of capacity for early psychosis services and location of these services in non-hospital environments that are more welcoming and appropriate for young people experiencing a first episode of mental illness

o) Accordingly, the recently vacated Ellimatta Lodge at Port Macquarie would provide an appropriate location for day programs and outpatient clinics for Youth and Family services in the Hastings Macleay Clinical Network

p) Enable greater involvement and input of consumers and carers in the planning, delivery and evaluation of mental health services including the establishment of a Mental Health Consumer Partnerships Coordinator at executive level. This position will develop a strategic plan for increasing consumer support positions within the LHD

q) Explore opportunities to increase supported accommodation, and associated rehabilitation services such as vocational training and living skills, for people with



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mental health conditions in the Mid North Coast, through the Mental Health and Drug & Alcohol Office and key partnerships with other government departments including Department of Housing, and increase ambulatory support for people living in supported accommodation in order to enable the earlier discharge of long stay patients in acute inpatient services

r) Take steps to improve the physical health of people with mental illness through a range of measures designed to address the physical health risk factors which are more prevalent for people with mental health conditions including higher smoking rates, poor diet and insufficient physical activity, and the metabolic effects of anti-psychotic medications

s) Improve mental health services for Aboriginal people, and reduce the gap in mental health between Aboriginal and non-Aboriginal people, through the training, recruitment and retention of an Aboriginal Mental Health Service workforce that is commensurate with the Aboriginal share of the Mid North Coast Population (5%), and by working in partnership with Aboriginal Medical services on the Mid North Coast in order to reduce the gap in mental health outcomes between Aboriginal and non-Aboriginal people

t) Develop specialist mental health services targeting the special needs of the growing refugee population in the Mid North Coast, particularly those with recent experience of trauma through the re-instatement of a Transcultural Mental Health position based at Coffs Harbour

u) Develop formal links with an academic health facility with the aim of developing a research capacity and partnering opportunities in the development of local strategies focussing on health promotion, prevention and early intervention .



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2 BACKGROUND The Mid North Coast Local Health District provides a range of hospital inpatient and community mental health services. Mental health services are managed on a LHD basis and provided in each of the two Service Networks, Hastings Macleay and Coffs. Mental health services provided in each Network include: Hastings Macleay Network

• Port Macquarie Mental Health Inpatient Unit • Port Macquarie Community Mental Health Service • Kempsey Mental Health Inpatient Unit • Kempsey Community Mental Health Service

Coffs Network

• Coffs Harbour Acute Mental Health Unit • North Coast Mental Health Rehabilitation Unit • Coffs Harbour Acute Care Service Community Mental Health • Coffs Harbour Extended Care Service Community Mental Health

These services are the focus of this planning process. In addition to these public mental health services, there is a range of non-government and private mental health services provided in the Mid North Coast. The development of a Mid North Coast Mental Health Clinical Services Plan in 2012 provides the opportunity to review population needs, service capacity requirements and models of care in the delivery of mental health services on the Mid North Coast. In planning the future role and capacity of mental health services in the Mid North Coast LHD it should be noted that this planning occurs within the context of the broader Mid North Coast



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Local Health District Strategic Plan and is alignment with the broad strategic directions outlined in that plan. Previous clinical service plans, particularly those for services in the Hastings Macleay Network have identified a shortfall in the provision of mental health services to meet population needs. There is a need to enhance services and replace out-dated facilities with contemporary buildings that support contemporary models of care, including a greater emphasis on primary, community and ambulatory care services. The population of the Mid North Coast is growing and ageing. The Mid North Coast population was approximately 200,000 in 2006. The Mid North Coast population is projected to grow by 22% between 2006 and 2021 to a population of 242,000. The Mid North Coast has a high proportion (19%) in the 65 years and over age group. This group is projected to increase by a further 69% between 2006 and 2021, at which time this age group will comprise 27% of the total population of the LGA. A Mental Health Services Strategic Plan (2007-2012) was prepared by the North Coast Area Health Service in June, 2007. Clinical services plans have been developed for Port Macquarie Base Hospital (2010), Kempsey Hospital (2006) and Coffs Harbour Base Hospital (2010). The development of the 2012 Mid North Coast Mental Health Clinical Services Plan presents an opportunity to incorporate updated population projections and latest activity data in the review of population needs and future service requirements for the Mid North Coast to 2016 and 2021. It presents an opportunity to review and update the proposed models of care and review previous service enhancement priorities and determine which should have the highest priority in the context of current and projected community demand and available resources. In the development of the Mid North Coast Mental Health Clinical Services Plan (2012), a range of NSW Health endorsed planning tools have been used to project future service needs including aIM2010, SiAM2006 and MH-CCP 2010, FlowInfo Version 11.0, DOHRS data and information provided by the Health Service. These have been used for trend analyses and NSW Statistical Local Area (SLA) Population Projections 2009 have been used to define local and regional populations.



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3 GUIDING PRINCIPLES

In developing the Mental Health Clinical Service Plan, the Mid North Coast Local Health District has adopted the following guiding principles:

I. Recovery Focus of Treatment and Care

II. Consumer Involvement – engagement of consumers and carers in care

III. Prevention and Early Intervention – emphasis on reducing the burden of illness caused by mental health conditions

IV. Quality and Excellence – in the provision of mental health care

V. Effective partnerships – collaboration with key partners including NGOs and Commonwealth funded services

VI. Recognition of Cultural Diversity – delivery of culturally appropriate services to indigenous and culturally and linguistically diverse consumers

VII. Commitment to Closing the Gap in indigenous health outcomes for Aboriginal people and families on the Mid North Coast

4 POLICY AND PLANNING FRAMEWORK

4.1 COMMONWEALTH REFORMS AND PRIORITIES In March 2010 the Australian Government announced “A National Health and Hospitals Network for Australia’s Future”. This was the Commonwealth Government’s response to the Final Report of the National Health and Hospitals Reform Commission Report of June 2009. In April 2010 the



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second part of the Reform Plan was released “A National Health and Hospitals Network: Further Investment in Australia’s Future”. In April 2010 the Commonwealth Government secured agreement with most Australian States through the National Health and Hospitals Network Agreement to implement a nationally unified and locally controlled health system which is universally accessible. There will be significant changes to the way health services are funded with the Commonwealth Government increasing its funding contribution for public hospitals and taking full responsibility for General Practice and primary health care services including community health services such as community nursing, generalist counselling, integrated care, general practice and primary care coordination programs, including Indigenous and rural and remote primary health care services. The Commonwealth will also take responsibility for primary mental health care services which target the more common mild to moderate mental illnesses, selected hospital avoidance programs, primary and secondary prevention programs for early intervention and care and coordination programs that focus on the management of patients with chronic disease in the community, screening programs for cancer delivered in the primary health care setting and immunisation. In addition the Commonwealth Government will establish arrangements to better integrate aged care with other parts of the health system. The Commonwealth will also work with Primary Health Care Organisations (to be known as Medicare Locals) to improve access to GP and primary health care services. Arrangements will need to ensure that aged care services are coordinated with hospitals and primary health care services and that these services work together to provide integrated patient centred care.

NA TIONAL MENTAL HEALTH REFORM National Mental Health Strategy The National Mental Health Strategy aims to improve the lives of people with mental illness and provides a framework for national reform of mental health services. The strategy comprises the National Mental Health Plan, the Mental Health Statement of Rights and Responsibilities and the National Standards for Mental Health Services. The fourth National Mental Health Plan was released in November 2009. National Standards for Mental Health These standards describe the core elements of quality mental health care. They focus on achieving positive results for consumers and carers and form the basis for continuous improvement and accreditation for mental health services across Australia. Council of Australian Governments (COAG) National Action Plan on Mental Health 2006-2011



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The National Action Plan provides the framework for significant new investment in mental health services by all Australian Governments. The Action Plan emphasises strong collaboration between levels of government and with non-government sectors – such as Medicare Locals. As part of the national health reform process, the Australian Government announced a $2.2 million package over five years to fund National Mental Health Reform in May, 2011. The reforms focus on five areas;

• Better care for people with severe and debilitating mental illness • Strengthened primary mental health care services • Prevention and early intervention for children and young people • Encouraging economic and social participation, including jobs for people with mental

illness, and • Improving quality, accountability and innovation in mental health services.

Major components of the Reform package include the Partners in Recovery Initiative, establishment of Early Psychosis Prevention and Intervention Centres (EPPIC), the headspace program targeting youth mental health services and expansion of the Access to Allied Psychological Services (ATAPS) Program. In particular, the Partners in Recovery initiative aims to:

• Facilitate better coordination of clinical and non-clinical services to deliver “wrap-around” support to meet the full range of an individual’s needs

• Improve referral pathways and strengthen partnerships with existing services • Further embed a community based recovery model of support and service delivery

throughout the mental health and related sectors, and • Adopt a ‘no wrong door’ approach to service access and referral2.

4.2 LOCAL HEALTH DISTRICTS Under the National Health and Hospitals Network Agreement, the NSW Government has established LHDs comprising of small groups of public hospitals with a geographic and functional connection, large enough to operate efficiently and to provide a reasonable range of hospital services, and small enough to enable the LHDS to be effectively managed to deliver high quality services. Figure 4.1 – An Integrated National Health and Hospitals Network

2 DoHA (2012) Partners in Recovery: Information Paper 1, July 2012



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Source: A National Health and Hospital Network for Australia’s Future LHDs are the direct managers of public hospital services with a professional Board and Chief Executive Officer responsible for delivering agreed services and performance standards, within an agreed budget, based on an annual strategic and operating plan, to give effect to the LHD Service Agreement. Boards will comprise of members with appropriate mix of skills and expertise to oversee and provide guidance to large and complex organisations.

4.3 MEDICARE LOCALS Medicare Locals will form a national network of primary health care organisations whose aim will be to improve integration of primary health care services and improve access to services. Medicare Locals are an integral part of the National Health Reform Agreement. Medicare Locals will be established as independent legal entities with links to local communities, health professionals, service providers and consumer and patient groups. The NHRA notes that the strategic objectives for Medicare Locals are:

• Improving the patient journey through developing integrated and coordinated services; • Providing support to clinicians and service providers to improve patient care; • Identifying the health needs of their local areas and development of locally focused and

responsive services; • Facilitating the implementation of primary health care initiatives and programs; • Being efficient and accountable with strong governance and effective management.

Medicare Locals and LHDs will be expected to share some common membership of governance bodies where possible. Medicare Locals will be expected to work closely, and establish a formal engagement protocol with LHDs. The Commonwealth has established 61 Medicare Locals nationally. It will be important that bridges are built between these Medicare Locals and relevant LHDs for the purposes of joint population health and services planning. Northern Rivers General Practice Network Ltd, in partnership with Tweed Valley General Practice, Hastings Macleay General Practice Network, Mid North Coast Division of General



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Practice, North Coast GP Training and Many Rivers Aboriginal Medical Service (AMS) Alliance has been selected to establish the North Coast NSW Medicare Local. Figure 4.2: North Coast New South Wales Medicare Local Source: http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/content/MediLocProfile_NorthCoastNSW

http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/content/MediLocProfile_NorthCoastNSW



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4.4 NATIONAL SAFETY AND QUALITY FRAMEWORK The Australian Health Ministers’ Conference tasked the Australian Commission on Safety and Quality in Health Care with developing a national safety and quality framework. The proposed framework is based on a vision for safe and high quality care for Australia and was approved in principle in April 2008. The Framework has three dimensions:

• Patient focused care that is respectful of and responsive to individual preferences, needs and values;

• Driven by information to improve the safety and quality of care, reduce unjustified variation in standards of care, and to improve patients’ experiences and clinical outcomes;

• Organised for safety - Organisational structures, work processes and funding models recognise and reward taking responsibility for safety.

This Framework and its supporting standards are designed to guide action to improve the safety and quality of the care provided in all health care settings over the next decade.

4.5 NEW SOUTH WALES On 4 April 2011 following the change of government in NSW the new Minister for Health and Medical Research, the Hon. Jillian Skinner, released a statement on the priorities for the future delivery of health services to the people of NSW. These included:

• A patient focus to improve access to timely, quality health care across NSW; • An emphasis on preventative health and better management of people with chronic

diseases; and • Strengthening of the public health system to improve patient access to timely, quality health

care. Additionally, the Minister articulated core values that are to guide the implementation of health care into the future. These were:

• Collaboration - Accepting that everyone from the Minister to the patient are all part of one team in one health system.

• Openness - Ensuring that facts are on the table and allowed to speak for themselves, no matter how embarrassing or uncomfortable they may sometimes be. Our processes must be transparent. People have a right to know how and why decisions are made, and who is making them. We also need to be up front about what it costs to deliver world-best health care.

• Respect - Insisting that everyone engaged in providing health care has a valued role; that there is no single source of wisdom and that listening is as important as talking. Acknowledging that everyone can make a contribution and should be given the opportunity to contribute, especially to a process of continuous improvement. Within a respectful health care system, we are able to give real meaning to the concept of accountability to our



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patients. • Empowerment - Enabling patients to take greater control of their own health care in

collaboration with care providers. Ensuring that decisions are based on clear information about what works best, how much can be afforded and where and when treatment is available. Acknowledging that for empowerment to work, there must be trust on all sides and at all levels, from the Minister, the Department, hospital administrators and care providers – doctors, nurses, allied health, carers and volunteers. Empowerment and accountability have to exist at every level in the health system. Responsible delegation of authority will be a hallmark of health administration in NSW.

NSW PLANNING CONTEXT

In September 2011 the NSW Government released a new State Plan which sets the strategic direction for the state of NSW. Under the new State Plan, the NSW Ministry of Health will play a key role in:

• Keeping people healthy and out of hospital; • Closing the Gap in Aboriginal infant mortality; • ‘Closing the Gap’ and improving Aboriginal Peoples health outcomes; • Improving outcomes in Mental Health; • Reducing potentially preventable hospitalisations; • Providing world class clinical services with timely access and effective infrastructure; • Reducing hospital waiting times; • Reducing unplanned readmissions; • Decreasing health care associated bloodstream infections; • Improving transfer of patients from EDs to wards; • Managing health services well and promoting local decision making; • Better protecting the vulnerable members of our community –child wellbeing; • Ensuring NSW is ready to deal with major emergencies and natural disasters; • Fostering opportunity and partnership with Aboriginal people.

The overall direction of any health planning process within NSW is governed by the strategic directions outlined in NSW 2021 A Plan to Make NSW Number One. More specifically, the Guide for the Development of Area Healthcare Services Plans provides a template for the development of Area Healthcare Service Plans and a planning framework for planning activities within the NSW Health system. The Guide outlines common elements and data requirements to be incorporated into clinical service plans. The Guide to the Role Delineation of Health Services indicates the support services, staff profile, minimum safety standards and other requirements that are required within a health facility to ensure that clinical services are provided safely and are appropriately supported. In relation to mental health services, the NSW Ministry of Health released A New Direction for Mental Health – NSW Health 2006. This is a 5 year plan to provide earlier and better access to a greater range of services than had been provided previously by public mental health services in



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NSW. This plan is significant in that for the first time the aim was to balance hospital focused care with community care. Other State-wide clinical service plans that are relevant to this planning exercise include the following NSW Health plans and guidelines:

• NSW 2021 A Plan To Make New South Wales Number One • NSW Health Service Plan for Specialist Mental Health Services for Older People, 2012 • Delivering Better Patient Journeys - (2008) • Towards 2030 - Planning for our changing population (2008) • Final Report of the Special Commission of Enquiry - Acute Care Services In NSW Public

Hospitals - Peter Garling SC (2008) • The health of the people of NSW – Report of the Chief Health Officer (2010) • Discussion Paper on Implementing the Federal Government’s ‘National Health and Hospitals

Network for Australia’s Future’ in NSW (August 2010) • Activity Planning Guidelines for Emergency Departments • NSW Health Policy/Guidelines and Clinical Redesign Models NSW Health Role Delineation

and Rural Hospital Role Delineation Guidelines • NSW Health Service Planning Handbook for Rural Planners (2006.)

4.6 MID NORTH COAST LOCAL HEALTH DISTRICT On 29 September 2010, the NSW Government outlined the future shape of our health system, with the announcement of 18 proposed LHDs. The Districts were established on 1 January 2010. The Mid North Coast LHD covers a geographic area from Red Rock near Woolgoolga in the north to Johns River in the south, and extending west to the Great Dividing Range where it shares a border with the Hunter New England LHD. The Mid North Coast LHD was created in 2011 through the splitting of the former North Coast Area Health Service (NCAHS) into Northern NSW and Mid North Coast LHDs. The Mid North Coast LHD comprises the Local Government Areas of Bellingen, Coffs Harbour, Nambucca, Kempsey and Port-Macquarie-Hastings. The LHD is divided into two Health Service Clinical Networks: Hastings Macleay (covering Kempsey and Port Macquarie LGAs) and Coffs Harbour (covering Bellingen, Coffs Harbour and Nambucca LGAs). Networking within the LHD can provide a number of benefits including complimentary development of services, standardisation of care and availability of appropriate policies, procedures and protocols for the delivery of care, appropriate training and development for clinicians within the District, an appropriate clinical governance and continuous improvement in the quality of service. Implementation of the new LHDs will provide opportunities to further develop linkages between all facilities in the LHD. Systems and processes will need to ensure clinical linkages between specialist



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services are supported and developed to realise opportunities to improve access to a range of health services for residents of the NNSW LHD. Specific local and regional clinical service plans that are relevant to this planning exercise include the following plans, reviews and guidelines:

Relevant documentation includes: • Mid North Coast Health Profile • Mid North Coast Asset Strategic Plan • Former NCAHS Healthcare Services Plan • Former NCAHS Mental Health Services Strategic Plan 2007-2012 • MNC LHD Strategic Plan 2012-2016 • Port Macquarie Base Hospital Clinical Services Plan 2010 • Current Models of Care operating in Mid North Coast LHD • Hastings Macleay and Coffs Network - Structure and Operations

MID NORTH COAST LOCAL HEALTH DISTRICT (MNC LHD) STRATE GIC

PLAN

The MNC LHD Strategic Plan 2012-2017 was prepared in consultation with staff and forms the basis of the District’s Business planning over the next 5 years. The objectives of the Strategic Plan will be achieved by working with many partners; these include the District’s Clinical Council, the Community Engagement Advisory Council, Aboriginal Community Controlled Organisations, non-government organisations, local government, the University Centre for Rural Health, Southern Cross University, aged care providers and the North Coast Medicare Local. Amongst MNC LHD priorities are strategies which seek to optimise health and wellbeing across the age continuum and to provide efficient, effective and safe hospital and community based care. The following features comprise the vision, purpose, strategic objectives and values of the MNC LHD3:

VISION • Quality and Excellence in Regional Healthcare.

VALUES

• Collaboration – Improving and sustaining performance depends on everyone in the system working as a team

• Openness – Transparent performance improvement processes are essential to make sure the facts are known and acknowledged, even if at times this may be uncomfortable

• Respect – The role of everyone engaged in improving performance is valued • Empowerment – There must be trust on all sides and at all levels with responsible delegation

of authority and accountability.

3 MNC LHD Strategic Plan 2012-2017



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STRATEGIC OBJECTIVES • MNCLHD Strategic Directions are illustrated in Figure 4.3 below

Figure 4.3 Mid North Coast Strategic Directions

The key policy directions from a State and local perspective reflected in the Mid North Coast Mental Health Clinical Services Plan are:

• It reflects the needs of the population to be served through a network model of service provision including between and within LHDs to ensure rural residents can access appropriate care in a timely manner;

• It harnesses technology, to enable new ways of providing patient care across rural and remote NSW such as Telehealth, diagnostics and the electronic health record;

• Ensuring safe and effective health service delivery to rural and remote residents; • It describes the linkages which support provision of timely access to world class health care

through a range of acute and sub-acute care options; • It supports improved outcomes in Mental Health; • It develops an integrated primary and community health care model of service with a focus

on hospital substitution; • It co-locates and integrates acute and community health services and adopts integrated

primary and community health care principles and practices; • It emphasizes working in partnership – private and public health service providers, other

Government departments, Local Council and non-government organisations; • It reduces duplication of and gaps in acute, primary and community health services; • It strengthens services provided in the community;



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• It places greater emphasis on prevention and early intervention; and It defines strategies to address issues related to workforce recruitment and retention, training and workforce innovation.

MI D NORTH COAST LHD ASSET STRA TEGIC PLAN

The Mid North Coast Asset Strategic Plan is based on service delivery plans. Asset strategic planning is a structured planning process aimed at linking future service needs to asset requirements and then developing appropriate strategies to ‘close’ the gap between the current asset base and that required to support service needs. This generally is in the form of asset capital investment, continued maintenance or asset divestment. The Asset Strategic Plan is aimed at optimising the use of the Local Health District physical assets in meeting the current and projected health needs of its catchment population. The Mid North Coast LHD Asset Strategic Plan includes within its top five capital works priorities the development of an acute adult mental health inpatient unit at Port Macquarie Base Hospital.

4.7 MID NORTH COAST ABORIGINAL HEALTH PARTNERSHIP

AGREEMENT

The Mid North Coast Aboriginal Health Partnership seeks to improve health outcomes for Aboriginal people across the Mid North Coast District through:

Providing a forum where the partners may consult, advise and negotiate on matters relevant to Aboriginal health:

• Co-operating in the identification of service gaps and the development of shared solutions.

• Developing agreed positions relating to Aboriginal health policy, strategic planning, equity in service allocation and distribution of resources and enhancements.

• Negotiating agreed positions to undertake joint projects e.g. Clinical Services Redesign, Aboriginal Maternal Infant Health Program, Aboriginal Chronic Disease and health promotion.

• Sharing information concerning proposed activities, including intended funding applications that may impact on other members of the Partnership, to avoid duplication.

• Ensuring that Aboriginal health retains a high priority in the District health system; that it is integrated as a core element in all Local Health District policies and services; and that effort is sustained.

• Promoting a partnership approach at all levels and forums within the region.



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5 SERVICE NEED

5.1 MID NORTH COAST The Mid North Coast consists of the five local government areas of Kempsey, Port-Macquarie-Hastings, Nambucca, Bellingen and Coffs Harbour.

Figure 5.1 Mid North Coast Local Health District

5.2 CURRENT AND PROJECTED POPULATION PROFILE In 2006, the estimated resident population of Mid North Coast was 199,392 persons. Table 5.1 below presents the population projections to 2021 using the approved Ministry of Health population projections. The Mid North Coast population is projected to increase by 21.6% to 242,397 in 2021.4 The Hastings Macleay Network and the Coffs Network are of comparable size, both having a population of around 100,000 in 2006. The projected population increase is slightly higher for Hastings Macleay with a projected population of 122,205 in 2021 compared to 120,192 for the Coffs Network. 4 NSW Health Population Projection Series 1.2009 (2010), Department of Planning & Statewide Service Development Branch, NSW Health, March 2009 & Estimated Residential Population at 30 June 2006, NSW (3235.0), Australian Bureau of Statistics, July 2007



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Table 5.1 Current and Projected Population, Mid North Coast, 2006-2021 Proj. Change (%)

Age Group LGA 2006 2011 2016 2021 2006-2021Kempsey 5,941 5,450 5,273 5,272 -11.3%Port Macquarie 13,011 13,336 14,012 14,833 14.0% Hastings Macleay Network 18,952 18,786 19,285 20,105 6.1%

0-14 years Nambucca 3,458 3,266 3,238 3,232 -6.5%Bellingen 2,604 2,473 2,453 2,537 -2.6%Coffs Harbour 13,658 13,945 14,706 15,770 15.5% Coffs Network 19,720 19,684 20,397 21,539 9.2%Mid North Coast 38,672 38,470 39,682 41,644 7.7%Kempsey 17,719 18,252 18,100 17,638 -0.5%Port Macquarie 42,310 45,798 48,012 49,678 17.4% Hastings Macleay Network 60,029 64,050 66,112 67,316 12.1%

15-64 years Nambucca 11,052 11,201 10,942 10,605 -4.0%Bellingen 8,045 8,134 8,037 7,775 -3.4%Coffs Harbour 43,243 46,867 48,988 50,273 16.3% Coffs Network 62,340 66,202 67,967 68,653 10.1%Mid North Coast 122,369 130,252 134,079 135,969 11.1%Kempsey 2,700 3,209 3,973 4,638 71.8%Port Macquarie 8,031 9,606 11,978 13,807 71.9% Hastings Macleay Network 10,731 12,815 15,951 18,445 71.9%

65-74 years Nambucca 2,128 2,502 3,044 3,499 64.4%Bellingen 1,255 1,428 1,685 1,949 55.3%Coffs Harbour 5,751 7,073 9,298 11,366 97.6% Coffs Network 9,134 11,003 14,027 16,814 84.1%Mid North Coast 19,865 23,818 29,978 35,259 77.5%Kempsey 1,750 1,808 2,047 2,475 41.4%Port Macquarie 5,972 6,579 7,332 8,988 50.5% Hastings Macleay Network 7,722 8,387 9,379 11,463 48.4%

75-84 years Nambucca 1,564 1,552 1,668 1,972 26.1%Bellingen 777 824 891 1,031 32.7%Coffs Harbour 3,974 4,338 5,031 6,350 59.8% Coffs Network 6,315 6,714 7,590 9,353 48.1%Mid North Coast 14,037 15,101 16,969 20,816 48.3%Kempsey 458 651 759 841 83.6%Port Macquarie 1,960 2,743 3,465 4,035 105.9% Hastings Macleay Network 2,418 3,394 4,224 4,876 67.6%

85+ years Nambucca 447 606 716 749 67.6%Bellingen 278 311 353 385 38.5%Coffs Harbour 1,306 1,860 2,292 2,698 106.6% Coffs Network 2,031 2,777 3,361 3,832 88.7%Mid North Coast 4,449 6,171 7,585 8,708 95.7%Kempsey 28,568 29,369 30,151 30,865 8.0%Port Macquarie 71,284 78,060 84,799 91,340 28.1% Hastings Macleay Network 99,852 107,429 114,950 122,205 22.4%

TOTAL Nambucca 18,649 19,126 19,607 20,058 7.6%Bellingen 12,959 13,170 13,419 13,677 5.5%Coffs Harbour 67,932 74,084 80,315 86,457 27.3% Coffs Network 99,540 106,380 113,341 120,192 20.7%Mid North Coast 199,392 213,810 228,291 242,397 21.6% Source: NSW

Health Population Projection Series 1.2009, Department of Planning & Statewide Service Development Branch, NSW Health, March 2009 & Estimated Residential Population at 30 June 2006, NSW (3235.0), Australian Bureau of Statistics, July 2007



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A profile of the population served by the Mid North Coast LHD is provided below:

SIG NIF ICANT CHARACTERIST ICS

• Population Growth: The Mid North Coast population is projected to increase by 21.6% between 2006 and 2021. NSW projected growth in the same period is 16.5%.

• Aged population: A feature of the Mid North Coast is the substantial aged population. Almost one-fifth (19.2%) of the total Mid North Coast population in 2006 were aged 65 years and over. This compares with 13.5% of the total NSW population aged 65 years and over in 2006. The aged population is projected to increase by 69% to the year 2021, at which time this population group will comprise 26.7% of the total population of the Mid North Coast. The population aged 85 years and over is projected to double between 2006 and 2021.

• Aboriginal population: In 2011, 5.0% of the Mid North Coast population were Aboriginal5. In NSW 2.1% identify as Aboriginal and Torres Strait Islander.6 Kempsey LGA has the largest number (3,114) and proportion of Aboriginal residents (11.1%) of any LGA on the mid north coast.

• Paediatric population: In 2006 19.4% of the Mid North Coast population were aged 0 - 14 years. This population is projected to increase by 7.7% to 2021. In 2021, the 0-14 population will comprise 17.2% of the total population of the Mid North Coast.

• Socio-economic status: Using the SEIFA scores (reference score for Australia is 1,000) all Mid North Coast LGAs have scores under 1,000, ranging from 901 (Kempsey) to 976 (Port Macquarie-Hastings).7 NSW has an IRSD score of 1,003 and an IEO score of 1,005.8

• Tourist population: The Mid North Coast is a popular tourist destination which places additional demand on emergency services during peak holiday periods.

5.3 EPIDEMIOLOGICAL PROFILE For the Mid North Coast LHD there are four key demographic features that impact on health status (burden of disease) and the need for health services:

• High population growth; • Large and growing aged population; • Low socio economic status; • High proportion of Aboriginal residents.

SO CIO ECO NO MIC STATUS

Economic status is closely associated with health and wellbeing. People who are economically disadvantaged experience poorer health than economically advantaged people. MNC LHD is one of the most disadvantaged LHDs in NSW with all LGAs scoring lower than the NSW average on most measures of socio-economic status. 5 ABS Community Profiles (Census 2011) 6 ABS estimated resident populations (Census 2001 and 2006) (HOIST) 7 ABS Socio-Economic Indexes for Areas, 2006 8 Population Health Division. The health of the people of New South Wales - Report of the Chief Health Officer 2008. Sydney: NSW Department of Health.



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The overall level of socio-economic disadvantage in the Mid North Coast region contributes to higher than average levels of health problems and demand for services. All LGAs within MNC LHD score lower than the NSW score on most measures of socio-economic status. According to the IRSD, all MNC LHD LGAs scored less than 1,000 for the Index of Relative Socioeconomic Disadvantage, and ranged from 901 in the Kempsey LGA to 976 in the Port Macquarie Hastings LGA (refer Table 5.2 below). The Index of Education and Occupation (IEO) reflects the general level of education and occupation-related skills of people within a geographical area. Variables are designed to measure levels of educational attainment, unemployment and occupation skill levels. According to the IEO, all LGAs within the MNC LHD scored less than 1,000 for the IEO, and ranged from 891 in Kempsey LGA to 971 in Bellingen LGA.

Table 5.2 SEIFA Scores by LGA, MNC LHD, 2006

LGA Index of Relative Socioeconomic Disadvantage

Index of Education and Occupation

Port Macquarie-Hastings 976 942

Kempsey 901 891

Nambucca 903 905

Bellingen 955 971

Coffs Harbour 964 948

NSW 1,003 1,005

In 2010, compared to the NSW average (18%), a higher proportion of Mid North Coast residents (29%) report difficulties accessing health care when needed, reflecting a range of potential barriers to health care in a rapidly growing rural area. These potential barriers include: relatively limited access to primary care providers including GPs; transport barriers reducing access to local health care services and; limitations in the range of acute services available within the local area.9

Throughout the North Coast there are on average 66.2 GPs (full-time equivalent) per 100,000 residents compared to the NSW average of 87.3.10 This relative shortage of primary care may be reflected in the relatively higher hospitalisation rate of Mid North Coast residents for ambulatory 9 Centre for Epidemiology and Research. New South Wales Population Health Survey: 2010 Report on Adult Health Sydney: NSW Ministry of Health, 2011 10 Population Health Division. The health of the people of New South Wales - Report of the Chief Health Officer 2011. Sydney: NSW Department of Health. Available at: http://www.health.nsw.gov.au/public- health/chorep/bod/bod_acs_ahs_gpacs.htm. Accessed (Nov 2009).

http://www.health.nsw.gov.au/public-



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care sensitive conditions in 2010/11 (2,923 per 100,000 compared to NSW average of 2,379 per 100,000).8 Ambulatory care sensitive conditions are those for which hospitalisation is considered potentially avoidable through preventive care and early disease management, usually delivered through primary health care (for example, by GPs or in community health centres).11

Life expectancy at birth for Mid North Coast males (78.1 years) and females (83.4 years) is slightly lower than the NSW averages (males 79.2 years, females 84 years)8.

Potentially avoidable mortality refers to premature deaths (persons aged less than 75 years) that theoretically could have been avoided given current understanding of causation and available disease prevention and health care. Mid North Coast males have a higher rate of potentially avoidable mortality (223.9 per 100,000) compared to the NSW average (197 per 100,000)8. The leading conditions contributing to premature deaths for North Coast residents include cancer (33.2% males, 46.7% females); cardiovascular diseases (32.8% males, 25.9% females); injury & poisoning (13.4% males, 8.3% females); respiratory diseases (6.6% males, 7.9% females); and digestive system diseases (4.3% males, 2.4% females). 10

While older people enjoy good mental health, a significant minority experience one or more mental or behavioural disorders (9.5% of older people), high levels of psychological distress (10.9%), or take medication for their mental wellbeing (24%). Mental health problems can cause considerable suffering for individuals, as well as having negative impacts on families and the wider community.12 It is one of the leading causes of the total burden of disease and injury in Australia13 and is associated with increased exposure to health risk factors, poorer physical health and higher rates of death from many causes including suicide.14 Discussion about mental health in older people tends to focus on dementia; however, functional disorders such as schizophrenia, anxiety disorders and clinical depression are more prevalent.15

Dementia is a major problem among older people. It is characterised by disturbed memory, thinking and other intellectual impairments accompanied by deterioration in emotional control and social behaviour. Dementia can be caused by a number of diseases that impair the brain. The most common is Alzheimer's Disease, which is responsible for about 70% of cases.16 Dementia is not an inevitable part of the ageing process, but it is common in the elderly and is very common in the very old. It is estimated that 6.5% of persons aged over 65 years and 22% of persons older than 85 years had dementia in Australia in 2006.17 Dementia is the greatest single contributor to the cost of care in residential aged care.18

11 Department of Human Services. The Victorian Ambulatory Care Sensitive Conditions Study, 2001–02. Victorian Government, 2004 12 WHO 2006: WHO 2006 Mental Health. Viewed 16 March 2007 www.who.int/mental_health/en/ 13 Begg et al. 2007: Begg S, Vos T, Barker B, Stevenson C, Stanley L & Lopez AD 2007. The burden of disease and injury in Australia 2003. PH 82. Canberra: AIHW 14 AIHW 2006c: AIHW 2006c. Australia’s Health 2006. Canberra: AIHW 15 Collier 2006: Collier E 2006. Mental health and functional mental disorder in older adults. Nursing Older People 18:25–32.). (Older Australia at a glance (4th edition). 22 November 2007; ISBN-13 978 1 74024 732 0; AIHW cat. no. AGE 52. http://www.aihw.gov.au/publications/index.cfm/title/10402 16 NCCH, 2006: National Centre for Classification in Health. The International statistical classification of diseases and related health problems, 10th Revision, Australian Modification (ICD-10-AM). Tabular list. Sydney: NCCH, 2006 17 AIHW, 2008: Australian Institute of Health and Welfare. Australia's health 2008. Cat. no. AUS 99. Canberra:

http://www.who.int/mental_health/en/

http://www.aihw.gov.au/publications/index.cfm/title/10402



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Most people with dementia also have other chronic health conditions such as oral health problems, fractures, osteoporosis, arthritis and urinary tract infections. For most people with dementia (67%) it is their main disabling condition.19 Dementia represents a significant challenge to health, aged care and social policy. In 2005 the Australian Government announced that dementia was one of the national health priorities.20

AB ORIGINAL PO PULATION

The traditional custodians of the land covered by MNCLHD are the Biripi, Gumbainggir, Dainggatti and Nganyaywana, Nations.21

In 2011, there were 10,083 Aboriginal people who identified as Aboriginal on the Mid North Coast, representing 5.0% of the total population (NSW average 2.1%).3 LGAs with the highest numbers of Aboriginal people are Kempsey (3,314), Coffs Harbour (2,816), Port Macquarie Hastings (2,416) and Nambucca (1,359).22

Aboriginal communities have higher proportions of children and young people and lower proportions of older people than non-Indigenous communities. Approximately half (50.4%) of the North Coast Aboriginal population are aged less than 20 years. Aboriginal people aged 50 years and over make up only 12.2% of the Aboriginal population compared to 38.7% for the overall population of NCAHS.21

The poor health status of Aboriginal people within the Mid North Coast area and the difficulties experienced in accessing preventative and primary health care services is illustrated by the hospital admission rate of potentially avoidable conditions for Aboriginal residents being 2.5 times higher than the rate for non-Aboriginal residents23.

The significant health disadvantage of Aboriginal communities continues, with life expectancy estimated to be 60.0 years for NSW Aboriginal males and 65.1 years for NSW Aboriginal females for the period 1996 to 2001. For both males and females the life expectancy for Aboriginal people is estimated to be almost 17 years less than for the general population.10

AIHW, 2008. Available at: www.aihw.gov.au/publications/index.cfm/title/10585 18 AE, 2005: Access Economics. Dementia estimates and projections, NSW and its regions. Report for Alzheimer's Australia NSW and NSW Health. Canberra: 2005. Available at: www.health.nsw.gov.au/pubs/2005/pdf/dementia_est.pdf 19 AIHW, 2006: Australian Institute of Health and Welfare. Dementia in Australia: National data analysis and development. AIHW cat. no. AGE 53. Canberra: AIHW, 2006. Available at http://www.aihw.gov.au/publications/index.cfm/title/10368 20 AIHW, 2006: Australian Institute of Health and Welfare. Dementia in Australia: National data analysis and development. AIHW cat. no. AGE 53. Canberra: AIHW, 2006. Available at http://www.aihw.gov.au/publications/index.cfm/title/10368 21 Population Health & Planning Directorate. Aboriginal Health & Wellbeing Strategic Plan 2008-2013: North Coast Area Health Service. 22 ABS Community Profiles (Census 2011) 23 www.healthstats.nsw.gov.au accessed 18 March 2012

http://www.health.nsw.gov.au/pubs/2005/pdf/dementia_est.pdf



http://www.healthstats.nsw.gov.au/



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5.4 SERVICE DEMAND

There are several methods for identifying the population demand for mental health services. The Mental Health Clinical Care and Prevention (MH-CCP) methodology provides an estimate of population need using epidemiological and treatment data for population groups24. It is also possible to analyse current patterns of utilisation of mental health services by residents of the Mid North Coast Local Health District.

5.4.1 Mental Health Clinical Care and Prevention Estimates of Current and Projected Population Need The MH-CCP was developed as a tool to assist systematic consideration of the requirements of comprehensive integrated mental health care and prevention across the lifespan in a population mental health framework. It utilises epidemiological and treatment data to estimate the proportion of the population at risk of needing care over a twelve month period25. The Mental Health Clinical Care and Prevention model indicates that overall rates of mental health problems in the community are relatively high at around 20%. However a relatively smaller number of people require specialist treatment for mental health issues. The model indicates that a full range of mental health programs are required across the life span from early childhood to old age and across the intervention spectrum from promotion, prevention and early intervention to acute care, continuing care and rehabilitation.

The MH-CCP presents age-specific prevalence estimates for varying levels of severity of mental health risks and disorders across the lifespan. For the purpose of informing the Mid North Coast Mental Health Plan, the four age groups are used:

• Children (age 5-11 years)

• Adolescents (age 12-17 years)

• Adult (age 18-64 years)

• Older People (age 65 years and over)

Overall, the MH-CCP indicates a projected prevalence of mental health problems with 16.6% of the population projected to experience a clinically diagnosable mental disorder. This translates to around 35,500 people in 2011 for the population of the Mid North Coast (as indicated in Table 5.3), and increasing to over 40,000 people in 2021. The MH-CCP estimates that, for the projected Mid North Coast population of 242,397 people in 2021, over a 12 month period that:

24 Ministry of Health (2012) Mental Health Clinical Care and Prevention Model, 2010 25 Mental Health and Drug & Alcohol Office, NSW (2001) Mental Health Clinical Care and Prevention Model Version 1.11 a population mental health model; Ministry of Health (2012) Mental Health Clinical Care and Prevention Model, 2010



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40,238 people, or 16.6% of the population, would experience a clinically diagnosable mental disorder

10,908 people, or 4.5% of the population, would experience moderate to severe problems that impair function and may be persistent and 23,270 people, or 9.6% of the population, would experience significant but milder problems.

6,060 people, or 2.5% of the population, would experience severe mental health problems, including psychotic disorders (ie schizophrenia, bipolar disorder), severe depression and anxiety disorders. People with these conditions form the primary target group for MNCLHD Mental Health Services.

Table 5.3 Current and Projected Population and Estimated Prevalence of Mental Disorders

by Network, MNCLHD 2011-2021

Projected Est. Popn living with Projected Est. Popn living with Projected Est. Popn living with Age Group Popn 2011 mental disorder Popn 2016 mental disorder Popn 2021 mental disorderChildren 16% 16% 16%Hastings Macleay 8,767 1,403 9,000 1,440 9,382 1,501 Coffs Harbour 9,186 1,470 9,518 1,523 10,052 1,608 Mid North Coast 17,953 2,872 18,518 2,963 19,434 3,109 Adolescents 20.60% 20.60% 20.60%Hastings Macleay 7,514 1,548 7,714 1,589 8,042 1,657 Coffs Harbour 7,874 1,622 8,159 1,681 8,616 1,775 Mid North Coast 15,388 3,170 15,873 3,270 16,658 3,432 Adults 17.80% 17.80% 17.80%Hastings Macleay 60,293 10,732 62,255 11,081 63,295 11,267 Coffs Harbour 62,265 11,083 63,888 11,372 64,345 11,453 Mid North Coast 122,558 21,815 126,143 22,453 127,640 22,720 Older People 13.30% 13.30% 13.30%Hastings Macleay 24,594 3,271 29,553 3,931 34,784 4,626 Coffs Harbour 20,495 2,726 24,978 3,322 29,999 3,990 Mid North Coast 45,089 5,997 54,531 7,253 64,783 8,616TOTAL 16.60% 16.60% 16.60%Hastings Macleay 107,429 17,833 114,950 19,082 122,205 20,286 Coffs Harbour 106,380 17,659 113,341 18,815 120,192 19,952 Mid North Coast 213,809 35,492 228,291 37,896 242,397 40,238

Source: NSW Health Population Projection Series 1.2009, Department of Planning & Statewide Service Development Branch, NSW Health, March 2009 & Estimated Residential Population at 30 June 2006, NSW (3235.0), Australian Bureau of Statistics, July 2007

5.4.2 Current Utilisation of Community Mental Health Services by Mid North Coast Residents

The Mid North Coast LHD has information on the total number of Mental Health Clients who are seen by the LHD Community Mental Health Service during the year. In 2011/12, the MNC Community Mental Health Service saw a total of 3,982 clients.



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Almost four out of five (78%) of total clients were adults between the age of 18-64 years (refer Table 5.4 below). Older people aged 65 years and over, who comprised 21% of the total MNC population in 2011, accounted for 7.7% of total community mental health clients. There were only 13 clients aged less than 12 years in 2011/12, and there were 564 clients aged 12-17 years, accounting for 14% of the total MNC community mental health client base.

Clients from Hastings/ Macleay over half of the total MNC mental health clients seen in 2011/12. Clients from Macleay accounted for around 22% of total mental health clients. In 2011, Kempsey had 13.7% of the total population of the Mid North Coast.

Note: The network totals of individual mental health clients in Table 5.4 will not add up to the LHD total as some individuals were active in more than one network.

Table 5.4 Individual Clients of MNC Mental Health Service by Clinical Network, 2011/12

Age Group Coffs Hastings Macleay Mid North Coast

%

0-11 Years 11 0 2 13 0.3

12-17 years 192 265 134 564 14.2

18-64 Years 1,621 938 725 3,100 77.9

65+ Years 155 123 66 305 7.7

TOTAL 1,979 1,326 927 3,982 100

Source: North Coast SCI-MHOAT, MNCLHD, 2012

Of the 1,703 active mental health community ambulatory clients at 8 October, 2012, 165, or 9.7% were identified as indigenous. An “active” client was seen by the service within the last 91 days. The proportion of indigenous clients by Network was 16.7% for Macleay, 7.6% for Hastings and 7.0% for Coffs. For comparison, the Aboriginal population of the Mid North Coast in 2011 comprised 5% of the total population.

5.4.3 Inpatient Separations for Mid North Coast Residents In 2010/11, residents of the Mid North Coast utilised a total of 1,892 hospital inpatient separations for mental health (refer Table 5.5/Table A1 at Appendix 1). The majority (97%) of these separations were for acute psychiatry (1,830 separations). The 62 separations for sub-acute or non-acute inpatient mental health had an average length of stay of 70 days and accounted for 4,354 bed-days which is equivalent to a daily average of 12 occupied beds.

The 1,830 acute inpatient separations had an average length of stay (ALOS) of 12.2 days and resulted in a total of 22,391 inpatient bed-days. These acute inpatient bed-days are equivalent to approximately 72 beds at 85% occupancy. It should be noted that these are the total inpatient separations for mental health for Mid North Coast residents. They include hospital separations in general hospital beds as well as in designated mental health units and they include use of private hospital facilities and hospitals in other local health districts outside of the Mid North Coast.



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Table 5.5 Mid North Coast Resident Demand by LGA for Inpatient Mental Health Services

Total Mental Health separations (all wards) 2010/11 Acute Sub/Non-Acute Total LGA of Residence Separations Beddays Separations Beddays Separations Beddays

Bellingen 90 1143 6 339 96 1482 Coffs Harbour 606 7739 19 1186 625 8925 Nambucca 129 1776 7 341 136 2117 Coffs Harbour Network 825 10658 32 1866 857 12524 Kempsey 360 3794 6 443 366 4237 Port Macquarie-Hastings 645 7939 24 2045 669 9984 Hastings Macleay Network 1005 11733 30 2488 1035 14221 MID NORTH COAST 1830 22391 62 4354 1892 26745

Source: NSW Health (2012) FlowInfo 11.0

The resident demand by LGA is presented in Table 5.5/Table A1, and aggregated for the two Clinical Networks. In 2010/11, the residents of Hastings Macleay Clinical Network utilised 1,035 separations and 14,221 bed-days for inpatient mental health services, comprising 53% of total mental health separations for the LHD. Residents of the Coffs Harbour Clinical Network utilised 857 separations and 12,524 bed-days.

The diagnosis related groups for these mental health inpatient separations is presented in Table 5.6 (and Table A2 at Appendix One). Patients with a primary diagnosis of schizophrenia accounted for 16% of the total separations and 30% of the total bed-days. The primary diagnosis of major affective disorders accounted for a further 15% of separations and 20% of bed-days.

In 2010/11, there were 40 separations for non-acute rehabilitation for Mid North Coast residents and these had an average length of stay of 103 days. There were 282 separations for personality disorders and acute reactions and the 2,415 bed-days for these separations accounted for 9% of total bed-days for Mid North coast residents.

Of the 1,892 total mental health inpatient separations for Mid North Coast residents in 2010/11, 1,187, or 63%, were provided within designated mental health inpatient units (refer Table 5.7a below (Table A3a in Appendix One). A further 705 separations were provided in non-designated units, ie general beds in public and private hospitals(refer Table 5.7b below (Table A3b in Appendix One).



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Table 5.6 Mid North Coast Resident Demand by Diagnosis Related Group for Inpatient Mental Health Services

Mental Health Separations 2010/11 Mid North Coast ResidentsDRG Separations Beddays Separations Beddays Separations Beddays ALOS Beds @ 85%

Total Mid North Coast 1187 24293 705 2452 1892 26745 14.1 86.2U61Z Schizophrenia Disorders 277 8116 23 115 300 8231 27.4 26.5U63Z Major Affective Disorders 208 4786 66 692 274 5478 20.0 17.7Z60B Rehabilitation W/O Catastrophic CC 37 3886 37 3886 105.0 12.5U67Z Personality Disorders and Acute Reactions 190 2011 92 404 282 2415 8.6 7.8U64Z Other Affective and Somatoform Disorders 87 920 80 343 167 1263 7.6 4.1V62A Alcohol Use Disorder and Dependence 32 629 32 629 19.7 2.0U62A Paranoia & Acute Psych Disorder W Cat/Sev CC or W Mental Health Legal Status 17 623 2 2 19 625 32.9 2.0B63Z Dementia and Other Chronic Disturbances of Cerebral Function 15 596 15 596 39.7 1.9U62B Paranoia & Acute Psych Disorder W/O Cat/Sev CC W/O Mental Health Legal Status 33 458 7 27 40 485 12.1 1.6V61Z Drug Intoxication and Withdrawal 31 419 31 419 13.5 1.4X62B Poisoning/Toxic Effects of Drugs and Other Substances W/O Cat or Sev CC 34 304 34 304 8.9 1.0Z60A Rehabilitation W Catastrophic CC 3 235 3 235 78.3 0.8U65Z Anxiety Disorders 22 229 55 231 77 460 6.0 1.5V60Z Alcohol Intoxication and Withdrawal 17 177 17 177 10.4 0.6U66Z Eating and Obsessive-Compulsive Disorders 8 148 9 259 17 407 23.9 1.3U60Z Mental Health Treatment, Sameday, W/O ECT 44 44 294 294 338 338 1.0 1.1Other DRGS 132 712 77 85 209 797 3.8 2.6

Total separations (all wards)Designated Wards All Other Wards


Around 74% of the inpatient mental health separations in designated units for Mid North Coast residents in 2010/11 were provided within Mid North Coast public hospital facilities (refer Table 5.7a below). In 2010/11 Coffs Harbour Hospital provided 497 separations for Mid North Coast residents, PMBH provided 196 separations and Kempsey Hospital, 150 separations, within their designated mental health inpatient units.

Table 5.7a Mid North Coast Resident Demand by Facility for Inpatient Mental Health Services

2010/11 % of total

Hospital Separations Beddays Separations Beddays Separations Beddays beddays

Coffs Harbour 473 9373 24 2240 497 11613 47.8%Port Macquarie 196 3852 196 3852 15.9%Kempsey 150 2427 150 2427 10.0% Sub-total MNCLHD 819 15652 24 2240 843 17892 73.7%Private Hospitals 186 2227 186 2227 9.2%Lismore 44 682 44 682 2.8%Manning 25 226 25 226 0.9%Bloomfield 1 23 9 1137 10 1160 4.8%Tweed Heads 7 60 7 60 0.2%Orange 3 18 4 147 7 165 0.7%Wingham 0 0 6 691 6 691 2.8%JF - Morisset 4 511 4 511 2.1%Other Hospitals 52 603 3 76 55 679 2.8%Total 1141 20002 46 4291 1187 24293 100.0%

Designated WardsAcute Sub/Non-Acute Total


A further 186 separations for Mid North Coast residents were provided in private hospital facilities, comprising 9% of the total bed-days for Mid North Coast residents. A further 158 separations were provided in various other public hospital designated units within NSW, including 44 separations at



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Lismore Base Hospital, 25 separations at Manning Base Hospital, Taree and 10 separations at Bloomfield Hospital, Orange.

Table 5.7b Mid North Coast Resident Demand by Facility for Inpatient Mental Health Services (Non Designated Wards)

2010/11 % of totalHospital Separations Beddays Separations Beddays Separations Beddays beddaysCoffs Harbour 216 283 216 283 12%Port Macquarie 101 278 101 278 11%Kempsey 97 129 97 129 5%Bellinger River 12 60 12 60 2%Wauchope 12 53 12 53 2%Macksville 9 106 9 106 4%Dorrigo 8 16 8 16 1% Sub-total MNC L 455 925 455 925 38%Private Hospitals 210 1337 210 1337 55%Other Hospitals 24 127 16 63 40 190 8%Total 689 2389 16 63 705 2452 100%

Other Wards (non-designated)Acute Sub/Non-Acute Total


Of the 705 mental health separations provided in non designated mental health beds for Mid North Coast residents, 455, or 65%, were provided within Mid North Coast public hospitals including 414 separations at Coffs Harbour, Port Macquarie and Kempsey hospitals (refer Table 5.7b above). There were also 210 separations and 1,337 bed-days provided by private hospitals within non-designated mental health beds. These comprise 5% of total mental health inpatient bed-days for Mid North Coast residents.



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6 CURRENT SERVICES

6.1 MID NORTH COAST LOCAL HEALTH DISTRICT Specialist Mental Health Services operate across the Mid North Coast LHD as a dedicated service, or “clinical stream”. The mental health clinical stream is part of a broad range of clinical services within the LHD that deliver services to mental health patients – including emergency departments and community health services. The Director, Mental Health and Drug & Alcohol is responsible for overall management of MNCLHD Mental Health Services, supported by the Director Medical Services/Clinical Director, Mental Health, District Manager, Mental Health Services and Manager, Nursing and Service Development in the provision of clinical leadership to the service. Each Clinical Network has a District Manager of Mental Health Services who is responsible for managing Mental Health services across the Network and for strengthening partnerships and liaison with other services. There are service managers in the clinical networks who are responsible for managing a unit of the Mental Health service, either in-patient or community. They are also responsible for strengthening partnerships and liaison with other services. In Coffs Harbour, due to the size of the services there, a site manager oversees the unit managers across the clinical network. A range of State and LHD-wide initiatives are developed, implemented, coordinated and evaluated from the LHD service. There are four “units” within the LHD Mental Health and Drug & Alcohol Service:

• Mental Health Services • Drug & Alcohol Services • Nursing and Service Development • Business Support

The Mid North Coast Local Health District provides a range of hospital inpatient and community mental health services. Mental health services are managed on a LHD-wide basis and provided in each of the two clinical networks, Hastings Macleay and Coffs Harbour. The core business of these services is illustrated in Figure 5.1 below. Mental health services provided in each clinical network include: Hastings Macleay Clinical Network • Port Macquarie Mental Health Inpatient Unit • Kempsey Mental Health Inpatient Unit • Port Macquarie Community Mental Health Service • Kempsey Community Mental Health Service

Coffs Harbour Clinical Network • Coffs Harbour Acute Mental Health Unit • North Coast Mental Health Rehabilitation Unit • Coffs Harbour Acute Care Service Community

Mental Health • Coffs Harbour Extended Care Service

Community Mental Health



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The Coffs Harbour Clinical Network has 142.5 hours per week of psychiatry services with a net total of 122 hours for direct clinical care. The Hastings Macleay Clinical Network has 148 hours per week of psychiatry services with a net total of 126 hours for direct clinical care. Description of the services provided by these mental health services and their models of care is presented in sections 6.2 and 6.3 below. Figure 6.1 Core Business of MNC LHD Mental Health Services

Family, Friends, Carers

Inpatient Services

Community Based Care

Early Intervention/Health Promotion

Community Development

Community Awareness

Education

Inpatient Care

Assessment

Acute Management

Rehabilitation

Discharge Planning

Community CareAssessmentCase Management

Care CoordinationConsultation

Care CoordinationPartnerships/NetworksEarly Detection/Early

InterventionConsultation liaison

Service linkagesProfessional training(eg School Link & Mental Health First Aid)

Health Promotion –Prevention – Early InterventionCommunity Dev.(eg Carers 14 Steps, Mental Health

First Aid)

SERVICETYPE

SKILLMIX

Mental HealthCore Business

Supported Accom

Assertive Management

Community Based

Government, NGO’s & Professional Services (Education, General Health, Docs, Premiers,

GP’s, Justice

Community Organisations & Interest Groups (Rotary, Scouts, Sports Clubs, Churches, etc)

Tertiary

Acute

Non-Acute



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6.2 HASTINGS MACLEAY CLINICAL NETWORK Public mental health services provided by the Hastings Macleay Network include the following four services:

6.2.1 Port Macquarie Mental Health Inpatient Unit Port Macquarie Mental Health Inpatient Unit (Ward 1A) is a 12 bed gazetted mental health in-patient unit with 10 low dependency beds and 2 observation/ low stimuli beds. Whilst there has been a significant growth in the local population over the last 15 years to well over 80,000 people there has only been an associated increase of 2 inpatient beds since the unit opened in the nineties. The Unit is staffed 24 hours a days, 7 days a week, with 3 nurses working each shift; inclusive of the CNS 2 Monday to Friday who carries a clinical load in addition to overseeing bed management etc. The Nursing Unit Manager Level 2 (NUM 2) works day duty, Monday to Friday. The morning and evening shifts are 8 hours long and the nights are 10 hour shifts.

The treating team is also made up of 2 Psychiatric VMOs , 1 Registrar on 3 month rural rotation, a Junior Medical Officer, as well as a full-time Social Worker and the Activity Officer Role, currently occupied by a nurse. Health Services Assistants (HSA) work in the morning and evening shifts 7 days a week. One administration officer works full-time, Monday to Friday.

The catchment area for the MHIPU extends from Johns River in the south to Macksville in the north ostensibly and out to the west as far as Ginger Creek. The Port Macquarie and Kempsey hospital inpatient mental health units operate as a single service for the Hastings Macleay Clinical Network. In view of the situation that PMMHIPU has gazetted beds and KHMHIPU does not, patient s are admitted , and transferred between, the two units based on patient needs and severity. In the broader context, the mental health inpatient units throughout the MNCLHD are required to cover periods of high bed pressure and patients sometimes requiring relocation under a reciprocal arrangement with the other mental health units in the MNCLHD, to best manage those periods of significant bed pressure.

Model of Care There is now a comprehensive range of activities and programs available to the patients on a seven day basis. These encompass educational, therapeutic and recreational activities and group work. The Unit works closely with MNC LHD services such as Community Mental Health Acute Care Team and Extended Care Service, Sexual Health, Child and Family Health, Emergency Dept., Mental Health Rehabilitation, Maternity, the Surgical & Medical Wards, and Community D&A Counsellors. Wound clinic, Infection Control and Diabetes educator, Pharmacy, Physiotherapy and the Dietetics departments also work with the Unit to address patient needs related tom their hospitalisation, as do the network educators and hospital clinical practice staff in fostering professional linkages for the purposes of education and collegiality between the general and mental health streams.



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6.2.2 Port Macquarie Community Mental Health Service

Community Mental Health Services (CMHS) provide community based care for people with mental health problems.

Model of Care New referrals are triaged and received from the Mental Health Access Line. Internally direct referrals are received from the PMBH Emergency Department (ED), PMBH Wards, MNCLHD Inpatient Units. Externally direct referrals are received from GPs, private psychologists, private psychiatrists, school & TAFE counsellors and Government and Non-Government partners.

Models of Care are in the process of development/introduction within the teams and they include: • Recovery focussed interventions across all teams • Recovery Support interventions – in line with services provided by NGO’s • Assertive Care Co-ordination across all teams • Collaborative care planning between team members and NGO’s

Key Service Linkages and Partnerships: Internal External

• General wards of Port Macquarie and Wauchope Hospital

• ED of Port Macquarie Base Hospital • Youth and Family Team • Aboriginal service • SMHSOP • Drug and Alcohol • Generalist Counselling Services • Clinical Governance • MHIPUs in MNCLHD • MH Rehab Unit (Coffs)

• Lismore Inpatient Psychiatric Unit • Nexus, Newcastle • Westmead Children’s Hospital • Sexual Assault Services • Head Injury Services • Police • Ambulance • FACS • Public Housing, Community Housing, Lands Council • MH NGOs • Private Housing providers e.g. Caravan Parks • GPs / Medicare Local • Private Psychiatrist’s & Psychologists • Headspace • Court liaison • Schools / school counsellors, School-Link • Aboriginal Medical Service (Werin)

6.2.3 Kempsey Mental Health Inpatient Unit The Kempsey Mental Health Inpatient Unit is a ten (10) bed voluntary unit. The Unit operates as an integrated service with the Port Macquarie Mental Health Inpatient Unit and gazetted patients are admitted to the Port Macquarie in-patient unit or the Coffs Harbour unit. The Kempsey Inpatient



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Unit accepts voluntary patients from the Port Macquarie-Hastings area, and at time from the Coffs Harbour area.

Model of Care Current Models of Care Include:

• Bio-psycho-social assessment and intervention

• Individual care plans with inclusion of social system intervention and recovery

• Integration of in-patient units and community care to ensure seamless transition of care

• Collaboration with other support services to provide stable accommodation and support.

A significant component of the model of care at Kempsey Hospital is the regular multidisciplinary clinical review meeting where progress is reviewed against the recovery model and discharge plans developed.


• General wards of Kempsey District Hospital

• Emergency Department (KDH, PMBH)

• Drug and Alcohol • Clinical Governance • ACS’s on Mid North Coast • MHIPUs on the Mid North Coast • MH Rehab Unit (Coffs)

• Aboriginal Medical Service • Police • Ambulance • Public Housing • Mental Health NGOs • Private Housing providers e.g. Caravan Parks • GPs • Sexual Assault Services

6.2.4 Kempsey Community Mental Health Service Community Mental Health Services (CMHS) provide community based care for people with mental health problems within the Macleay Valley. In organisational terms, these services are divided into the following teams, but clinically they operate as an integrated service and all services are managed by Community Mental Health Manager NUM2. Acute Care Services

The Acute Care Team-operates from 8.30am to 9.30pm, 7 days per week. Its function is to receive and process referrals to CMHS, provide acute assessment and more intensive community based management, including post discharge management from Mental Health Inpatient Units (MHIPUs). This team will also work closely with the various parts of the Extended Care Service Acute Care Services are complimented by input from an On Call Consultant Psychiatrists. It is made up of a multi-disciplinary team of Registered Nurses, and has 5.0 FTE including CNC ED liaison.

The social worker and nursing staff are provided clinical leadership by the Clinical Nurse consultant ED Liaison.



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Extended Care Services (ECS)

The ECS operates Monday to Friday during business hours and has 7.0 FTE.

Extended Care Case Management- provides individual case management for clients over 18 years. ECS staff operates within the Recovery Model and provide specialist rehabilitation for clients with mental illness. The service includes individual and group centre based activities at Wide Street Therapy Centre Kempsey, outreach clinics at South Rest Rocks Community centre. The ECS team also provides intensive short term Therapy as well as Dialectic Behavioural therapies service. The ECS is staffed by Social Workers Registered Nurses and Psychologist and Clinical Psychologist. The team is supported by Senior CMO 3 days per week. There is also a Youth and Family team of 2 FTE.

Model of Care Referrals are triaged and received from the Mental Health Access Line and direct referrals are received from, Emergency Department and general hospital staff, General Practitioners Medical Specialists (including psychiatrists and paediatricians), Community Health staff, including Sexual Health, Sexual Assault and AOD staff, School Counsellors, Justice Health Court Liaison CNC and, Mental Health NGO Workers.

A feature of the Kempsey Community Mental Health Team is the involvement of 0.6 FTE CMO on the team who sees patients on a 4-6 weekly cycle and coordinates the multidisciplinary clinical review meetings. This provides the opportunity for team members to have regular input, case review and discussion of progress with clients. This has the overall impact of reducing admissions and/or length of stay for acute admissions.

6.3 COFFS HARBOUR CLINICAL NETWORK Public mental health services provided by the Coffs Network include the following four services:

6.3.1 Coffs Harbour Acute Mental Health Unit (CHAMHU) The CHAMHU is a gazetted 30 bed Acute mental health in-patient unit with 6 High Dependency Unit beds (HDU) and 24 Low Dependency Unit beds (LDU). It is staffed 24 hours a day, 7 days a week with 10 staff on day duty, 9 staff on evening duty and 4 staff on night duty. All shifts are 8 hours except the night duty shift which is 10 hours. There is a Nursing Unit Manager Level 3 (NUM 3) on day duty, Monday to Friday and a clinical NUM 1 on a morning and afternoon shift 7 days a week. The unit is complemented with Psychiatrists, Registrars, a Group Program Coordinator, 1.2 FTE Social Worker, a Nurse Educator, Health Services Assistants, Hotel Services staff and Administrative staff. The catchment area for the unit is primarily between Eungai Rail south of Coffs Harbour and Red Rock to the north. Within the Coffs Harbour catchment there are 3 Local Government Areas (LGA’s) – Nambucca LGA covering Macksville and Nambucca Heads; Bellingen LGA covering Bellingen and Dorrigo; Coffs Harbour LGA covering Coffs Harbour and Woolgoolga.



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Model of Care Bed occupancy, average length of stay and workload for CHAMHU is impacted by the requirement to accept some Hastings Macleay Network clients whom require a gazetted mental health bed, due to the limited gazetted beds in Port Macquarie and the non gazetted beds in Kempsey. This also impacts on the Coffs Harbour Emergency Department.

Due to the ongoing pressure for beds over the area there are times when care is limited to crisis management only. The CHAMHU has a nursing model of care based on patient allocation. The nurse is responsible for coordination of all facets of patient care. Care is patient focussed and the treating team ensures family and carers are included in care delivery. There is a high dependence on Fly-in/Fly-out psychiatrists, with some locally resident psychiatrists also providing treatment. The unit has recreational, educational and therapy based group programs. Currently, ECT is provided in Coffs Harbour for patients of both the Coffs Harbour and Hastings/Macleay areas. The requirement to cover the latter area reduces access to this treatment for the patients of the CHAMHU. Key Service Linkages and Partnerships: Internal External

• Acute Care Team • Extended Care Service • Sexual Health • Child and Family Health • Emergency Dept. • Mental Health Rehabilitation, • Maternity, • Surgical & Medical Wards • Community D&A Counsellors • Community nurses, • Wound clinic and • Diabetes educator.

• Court Liaison CNC, • GP’s • Private Psychiatrists and Psychologists • Local Health District Hospitals • NGO’s (ONTRACK HASI) • NSW Health Rehabilitation Units • private security • Probation & Parole • Police • DOCS • Centrelink and • Department of Housing. • Aboriginal Medical Service • Mission Australia • CHESS PHAMS • Headspace

6.3.2 North Coast Mental Health Rehabilitation Unit The North Coast Mental Health Rehabilitation Unit is a 20 bed inpatient mental health rehabilitation unit. The Unit is a declared unit under the Mental Health Act. It accepts both voluntary and detained patients. The expected length of admissions is three to six months.



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The catchment area for the Unit includes both Mid North Coast and Northern NSW LHDs.

Model of Care The Unit provides a tertiary service, clients referred from any case management mental health service. Referrals assessed against eligibility criteria with face to face or videoconference meeting. The focus of admission is on functional gain with mental health recovery. Recovery in mental health is a model of care which aims to help the client achieve their potential despite their illness, not by focussing on their illness. The model of care includes – multidisciplinary care by nursing, psychiatry, medicine, clinical psychology, social work & occupational therapy. Assessment based on all standard mental health assessment tools, plus use of Mental Health Recovery Star as an assessment of ‘stage of change’ with regard to recovery journey. Care plan and interventions tailored to suit stage of change of client. Two staff identified as care coordinators for client, responsible for assessment, care planning, effective liaison, care review. Key therapeutic interventions include: Wide ranging activity program delivered by all staff, CBT, motivational therapy, psychopharmacology. Large inclusion of external community focused activity. Environment focusses on consumer involvement in communal living. Significant relationship with network rehabilitation coordinators of MNCLHD & NNSWLHD, part of mental health extended care services, all referrals via rehab coordinators. Local relationship with NGO mental health and disability services, shared provision of therapeutic activities. Local relationship with Coffs Harbour Acute Mental Health Unit, managing overflow clients. Local relationship with CHHC ancillary services.

6.3.3 Coffs Harbour Acute Care Service Community Mental Health The Acute Care Service provides community based care for people with mental health problems. The Acute Care Services (ACS) operates 7 days per week 365 days a year and provides assessment and acute care in the community setting.

This team operates from 8.00am to 10.00pm, 7 days per week.

The service’s function is to receive and process referrals for mental health care. This includes initial provision of priority care according to the urgency of response rating. Acute assessment is attended and more intensive community based management for some clients is required. Clients may also be admitted to the Coffs Harbour Acute Mental Health Unit (CHAMHU) where required. All discharges from the CHAMHU including some early discharge are managed by the ACS who will also work closely with the various parts of the Extended Care Service .



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Model of Care Referrals are triaged and received from the Mental Health Access Line and direct referrals are received from Emergency Departments (EDs) and service partners such as Drug and Alcohol Services, GPs and NGOs.

Acute Care Services are complemented by input from a Psychiatric registrars and or Consultant Psychiatrists. There is a consultant psychiatrist on call to the ACS.

The ACS provide assessments in the Coffs Harbour Emergency Department Monday – Friday by the Mental Health Clinical Nurse Consultant Emergency Department. From 1630 – 2200 hours Monday – Friday ED is covered by the ACS as are weekends 0800 – 2200 hours. The CNC also provides consultation and liaison to the Coffs Harbour hospital wards this is only Monday to Friday. The ACS interfaces with the following service components:

Case Management is provided by referral to the Extended Care Services (refer 5.3.4 below) which operates Monday to Friday during business hours.

Adult Case Management- provides individual case management for clients over 18 years – this Service based at Coffs Harbour, Macksville and Bellingen. There is also a Youth and Family Service based at Coffs Harbour that provides care to people 12- 18 years of age. There is also outreach from this service to Macksville, Dorrigo and Bellingen

Current Models of Care Include: • Bio-psycho-social assessment, treatment and intervention model of care • Individual acute support and recovery management with inclusion of social system

intervention • Integration of community care to ensure seamless transition of care to and from inpatient

services • Collaboration with other support services to provide stable accommodation and support Key Service Linkages and Partnerships: Internal External

• General wards of Hospitals • ED’s of Coffs Harbour, Macksville and

Bellingen hospitals • Drug and Alcohol • Generalist Counselling Services • Clinical Governance

• Head Injury Services • Sexual Assault Services • Police • Ambulance • FACS • Public Housing • MH NGOs • Private psychiatrists • GPs • Aboriginal Medical Service • Division of General Practice • Schools/school counsellors



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6.3.4 Coffs Harbour Extended Care Service Community Mental Health The Extended Care Service (ECS) Community Mental Health Team provides case management for mental health clients. The service operates Monday to Friday during business hours from 8.30am to 5.00pm. The service comprises the following service components:

• Adult community clinical rehab and recovery which includes case management; this service is based in Coffs Harbour, with outreach services based at Bellingen and Macksville. The referral criterion includes clients with a serious mental illness and clients with extended risk and disability associated with complexities surrounding mental illness.

• Youth and Family mental health service (YAF) which provides services for clients aged 12 -18, this service is based in Coffs Harbour and covers the Coffs Harbour region, and Bellingen and Nambucca Shire.

• Child and Adolescent (CAMHS) CNC Liaison; this position provides assessment, education and support to Paediatrics and other CHHC wards who currently have child and adolescent in-patients with mental health concerns, plus senior clinical consultation and support on child and adolescents within the mental health service.

• Older Persons Mental Health service – 1 clinician in Coffs Harbour and 1 in Macksville. Specialist mental health extended care support for clients 65 and over or 45 and over for Aboriginal clients.

• Aboriginal Mental Health Liaison worker ( this position works across all of Coffs Harbour Mental Health Service to ensure appropriate cultural safety and support for Aboriginal clients)

• Rehab and Recovery Service based in Coffs Harbour; this includes the Vocational, education, employment and training position; (VETE) Rehab Coordinator ( this position is the key link between disability support NGO’s and Rehab Unit); Rehab support worker position ( This position provides short term intensive rehab / living skills support)

• Currently the District wide School link Coordinators position is based in Coffs Harbour. ( this position coordinates the links between the YAF service and school counsellors, including ongoing education and support for the School Counsellors on mental health)

• Aboriginal Maternal Infant Health mental health service AMIHS MH & D&A (based at Galambila) this is a new position yet to commence. Part of this program is an Aboriginal mental health trainee who has already commenced in Coffs Harbour mental health service.

The Extended Care service is a multi-disciplinary team incorporating; Registered Nurses (Including CNC’s, & CNS’s), Social Workers, Psychologists (including Clinical Psychologist) & Occupational Therapists.

Model of Care Current models of care provided by the ECS include:



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• Bio-psycho-social assessment and intervention • Individual case management including therapy interventions such as CBT, DBT, Narrative,

trauma based therapies; plus psycho-education and mental health rehab and recovery treatment interventions.

• Psychiatry and Medication treatment • Family and Carer supportive counselling, education and linking with carers support services • Integration with Community Acute Care Service, Coffs Harbour Acute In-patient Unit, and NC

Mental Health Rehab Unit. • Priority allocation and intensive rehab and recovery focus for clients with early psychosis as

per Early Psychosis National guidelines. • Strong partnership with Headspace Young Persons service to ensure collaborative treatment

pathway for young people • A strong focus of re engaging clients into education, training or employment • Collaboration with other Government and Non – Government services to ensure access to

stable accommodation and extended disability support


• Drug and Alcohol services

• Child and Family counselling service ( for under 12 year olds – access to CAMHS Psychiatry in our service)

• Paediatric Unit

• NC MH Rehab Unit • All Acute MH Units in the region • Emergency Departments, within the

region

• ACAT • Sexual Assault Services • Brain Injury • Dietician • Diabetes CNC

• Community Generalist Nursing (especially in relation to OPMH)

• Clinical Governance and Patient safety officer

• Occupational Health and Safety Committee

• Refugee physical health clinic • Aboriginal Health

• Child & Adolescent Unit (Lismore)

• HeadSpace – Youth Mental Health Service • ADAC • Police

• Ambulance • Medicare Locals including private counsellors and

GP’s

• Baringa Private Mental Health Service ( new service)

• Mental Health NGO’s – New Horizons (HASSI) On Track Accommodation support program, CHESS PHAM’s program

• CHESS employment service

• Advance Personal Management Disability employment service ( currently part of our co-location project)

• Family and community Services • Housing – includes DOH and community housing • Rough Sleepers program

• Schools – counsellors • Youth Refuge and Youth centres in region • Anglicare –Settlement Refugee Program • STTARTS • Galambila Aboriginal Medical Service • Darimba Ma AMS



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6.4 NON GOVERNMENT ORGANISATIONS

6.4.1 NGOs funded via NSW Ministry of Health The NGO Grant Funded Programs directly funded through Mid North Coast LHD Mental Health and the NSW Mental Health and Drug and Alcohol Office are:

Centacare

Purpose: Centacare provides individual outreach support for 10 consumers at any point in time in Hastings Macleay Network . Outreach support will be maintained at the delivery of 3.8 hours each week for each consumer. This however, can be provided in a flexible manner depending on consumer need. The total hours of consumer outreach support is to be acquitted each month and reported to Mental Health Services. Non delivered Outreach Support hours will also be acquitted and redirected into direct outreach support service provision.

Geographic region: Port Macquarie and Kempsey within the Mid North Coast Local Health District. Number of places: 10 clients per week to be supported.

On Track Community Programs Ltd. (Moomba)

Purpose:

1) Residential Rehabilitation

On Track Community Programs provides and maintains a six (6) bed residential rehabilitation facility located in the Coffs harbour local government area. The facility services consumers referred from Mental Health Services and operates twenty four (24) hours each day, seven (7) days each week. The six (6) beds will be maintained at an occupancy rate of 85% and above.

2) Outreach Support

On Track Community Programs provides individual outreach support for twenty (20) consumers in Mid North Coast Local Health District. Outreach support will be maintained at the delivery of five (5) hours each week for each consumer. Non delivered Outreach Support hours will be acquitted by On Track and redirected into direct outreach support service provision.

Geographic region: Coffs Harbour Local Government Area

Number of places: 6 x 24 hour residential rehabilitation beds

100 hours per week in home outreach support to 20 consumers



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HASI Programs:

1) New Horizons

Geographic region: Coffs Harbour Local Government Area

Number of packages : 4 High (3A)

4 Low (H in Home 4B)

7 Low ( Hasi 2)

Funding: Centralised funding through MHDAO

2) New Horizons

Geographic region: Port Macquarie and Kempsey Local Government Area

Number of packages : 4 High (3A) 1 in Port Macquarie ; 3 in Kempsey

3 Med (H in Home 4B) 2 Port Macquarie; 1 Kempsey

6 Low (H in Home 4B) 5 Port Macquarie; 1 Kempsey


3) Mission Australia

Geographic region: Port Macquarie and Kempsey Local Government Area

Number of packages : 4 High (3A) Port Macquarie

8 Low ( Hasi 2) 4 Port Macquarie and 4 Kempsey

2 Low ( Aboriginal HASI) 1 Port Macquarie and 1 Kempsey


RRSP Programs:

1) New Horizons

Purpose: To assist consumers to identify and engage in social, leisure, recreation and vocational opportunities in their local community.

Geographic region: Port Macquarie and Kempsey Local Government Areas


6.4.2 Other NGOs



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In addition to these organisations directly funded by the NSW Ministry of Health, the following mental health NGOs are based on the Mid North Coast:

Mission Australia – Family and Carers Mental Health Program (funded by MHDAO) Located at both Coffs Harbour and Port Macquarie. Provides education and training for carers, active support for peer support groups and referral to respite and counselling services.

MH specific Employment Services (DES) – help to reach employment goals

Endeavour Clubhouse – opening soon. Vocational model. Place where people can go during the day.

6.4.3 Commonwealth Funded Services Headspace (Coffs Harbour) offers early intervention service for 12-25yo. The service has 4 GPs and 4 psychologists (all P/T), 2 youth workers and 2 visiting psychiatrists. The service is already facing demand management issues. A Headspace service will be opening in Port Macquarie in 2013 following successful tender by EACH service.

Medicare Locals have employed two mental health nurses – offer more immediate response than psychologists. Freeze on program at moment. Nurses seeing clients via direct referral from GP. Headspace also uses mental health nurses because of waiting list to see psychiatrist. Interim measure which enables immediate response and commencement of therapeutic process.

Personal Helpers and Mentors (PHAMS) services assist people recovering from a mental illness episode to build their confidence and overcome social isolation through a strength-based recovery program. These services provide group work as well as individual support. The two services operating within the Mid North Coast are:

• Coffs Harbour Employment Support Service (CHESS) operates from Yamba to Stuarts Point and has approximately 70 people on its books at any one time

• New Horizons (Hastings Macleay) operates from Hat Head to Laurieton and has approximately 60 people on its books at any one time

6.5 PRIVATE SERVICES

The Baringa Private Hospital at Coffs Harbour has a 12 bed mental health facility, the Bindarray Clinic. All patients are admitted on a voluntary basis to the clinic under the care of a Specialist Psychiatrist and supported by a team including psychologists, nursing and allied health staff.

Advanced Personnel Management (APM) co-located two days per week at Coffs Harbour Mental Health Service. This program was established in late 2012 and has already assisted 13 people to gain employment.



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7 CURRENT ACTIVITY

7.1 ACUTE INPATIENT MENTAL HEALTH SERVICES

There are three Acute Adult Inpatient Mental Health Units on the Mid North Coast: Coffs Harbour Health Campus (30 beds), Port Macquarie Base Hospital (12 beds) and Kempsey Hospital (10 beds). These Units provide intensive psychiatric care for people who are experiencing the effects of mental illness and mental disorder. These units have the capacity to accommodate both voluntary and involuntary patients, except for Kempsey which provides for voluntary admissions only.

In 2010/11 these three units provided a total of 944 separations (refer Table 7.1 below). The average length of stay was 18.6 days, ranging from 16.6 days at Kempsey Hospital to 19.7 days at PMBH. These units had a very high occupancy: 99.6% at Coffs Harbour and 94% at PMBH.

Table 7.1 Inpatient Activity for Mid North Coast Acute Mental Health Units, 2008/09-2010/11

2008/09 2009/10 2010/11 Hospital Separations Beddays Separations Beddays Separations Beddays ALOS Beds @ 90%

Coffs Harbour 555 10579 530 11310 580 10910 18.8 33 Port Macquarie 195 4483 211 4242 209 4114 19.7 13 Kempsey 246 2849 201 2947 155 2506 16.2 8 Total 996 17911 942 18499 944 17530 18.6 53 Source: NSW Health (2012) FlowInfo 11.0

The casemix of these units is summarised in Table 7.2 below. The majority of separations (65%) and bed-days (79%) were for three DRGs: schizophrenia, major affective disorders and personality disorders and acute reactions. The average length of stay for schizophrenia admissions is almost 30 days and is over three weeks for major affective disorders.

Of the total 944 acute inpatient separations provided by the three MNC units in 2010/11, 819, or 87% were for residents of the Mid North Coast (refer Table 7.3 below). Of the 125 separations provided to residents of districts outside the Mid North Coast, 62 separations or half of these flows, were from the Clarence LGA which borders Coffs Harbour to the north, and was formerly part of the Coffs Clarence Network.

The Coffs Harbour Acute Mental Health Unit primarily serves the Coffs Harbour, Nambucca, Bellingen and Clarence LGAs with a small number of separations (4% for each) from Kempsey and Port Macquarie LGAs.

The Port Macquarie Base Hospital Inpatient Unit primarily serves the local Port-Macquarie-Hastings LGA (80%) and Kempsey LGA (18%). Kempsey Hospital provides for residents of both Kempsey (53%) and Port-Macquarie-Hastings (45%).



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Table 7.2 Inpatient Activity for Mid North Coast Acute Mental Health Units by DRG

2010/11 DRG Separations Beddays ALOS U61Z Schizophrenia Disorders 285 8413 29.5 U63Z Major Affective Disorders 183 4477 24.5 U67Z Personality Disorders and Acute Reactions 149 940 6.3 U64Z Other Affective and Somatoform Disorders 84 856 10.2 U62B Paranoia & Acute Psych Disorder W/O Cat/Sev CC W/O Mental Health Legal Status 39 554 14.2 X62B Poisoning/Toxic Effects of Drugs and Other Substances W/O Cat or Sev CC 33 322 9.8 V61Z Drug Intoxication and Withdrawal 31 418 13.5 U62A Paranoia & Acute Psych Disorder W Cat/Sev CC or W Mental Health Legal Status 19 629 33.1 V60Z Alcohol Intoxication and Withdrawal 19 153 8.1 X60B Injuries W/O Catastrophic or Severe CC 13 67 5.2 U65Z Anxiety Disorders 13 103 7.9 B63Z Dementia and Other Chronic Disturbances of Cerebral Function 12 121 10.1 V64Z Other Drug Use Disorder and Dependence 11 32 2.9 V62A Alcohol Use Disorder and Dependence 11 75 6.8 X62A Poisoning/Toxic Effects of Drugs and Other Substances W Cat or Sev CC 8 57 7.1 X64B Other Injury, Poisoning and Toxic Effect Diagnosis W/O Cat or Sev CC 5 40 8.0 U60Z Mental Health Treatment, Sameday, W/O ECT 4 4 1.0 U66Z Eating and Obsessive-Compulsive Disorders 4 61 15.3 Z64A Other Factors Influencing Health Status 4 16 4.0 Other DRGs 17 192 180 Grand Total 944 17530 18.6




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Table 7.3 Inpatient Activity for Mid North Coast Acute Mental Health Units by LGA of Residence for Mid North Coast Residents

2010/11 Hospital LGA of residence Separations Beddays % of Hospital Total Separations Coffs Harbour Bellingen 43 882 9% Coffs Harbour 332 6117 70% Kempsey 18 805 4% Nambucca 62 1262 13%

Port Macquarie-Hastings 18 307 4%

Coffs Harbour Total 473 9373 100% Port Macquarie Bellingen 1 11 1% Coffs Harbour 1 35 1% Kempsey 36 756 18% Nambucca 1 43 1%


Port Macquarie Total 196 3852 100% Kempsey Coffs Harbour 2 12 1% Kempsey 79 1307 53% Nambucca 1 4 1%


Kempsey Total 150 2427 100% Grand Total 819 15652 Source: NSW Health (2012) FlowInfo 11.0



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7.2 NON-ACUTE INPATIENT MENTAL HEALTH SERVICES

The Rehabilitation Unit at Coffs Harbour Health Campus (20 beds) provides the only sub-acute or non-acute inpatient mental health services on the Mid North Coast. In 2010/11, there were 34 separations with an ALOS of 100 days. In 2010/11 the Rehabilitation Unit was not long opened and the activity levels reflected this developmental period, with an average utilisation of around 12- 13 beds. Activity levels and overall occupancy increased significantly in 2011/12.

Patients were predominantly residents of the Mid North Coast (70%) or Northern NSW (26%) as indicated in Table 7.4 below.

Table 7.4 Inpatient Activity for Mid North Coast Mental Health Rehabilitation Unit by LGA of Residence for Mid North Coast Residents

LGA of Residence Separations Beddays Coffs Harbour 10 1069 Port Macquarie-Hastings 5 616 Nambucca 4 132 Bellingen 3 328 Clarence Valley 3 254 Tweed 3 303 Lismore 2 415 Kempsey 2 95 NSW NFA 1 156 Ballina 1 43 Grand Total 34 3411


7.3 COMMUNITY MENTAL HEALTH SERVICES

In 2011/12, the Mid North Coast Community Mental Health Services had a total of 3,982 individual clients, as presented in Table 5.4. Service contact counts are the primary means of determining the activity of the community ambulatory mental health services. In 2011/12 the community mental health services provided a total of 64,490 contacts for these 3,982 clients, an average of 16 contacts per client.

Note: This information excludes contacts with non-identified clients. Clinical contacts that are not attributed to an individual client are also excluded.

The Coffs Network provided 29,502 contacts, representing 46% of the total MNC community ambulatory contacts, and an average of 15 contacts per individual client. The Hastings Network provided 16,656 contacts, representing 26% of the total MNC community ambulatory contacts, and an average of 13 contacts per individual client. The Macleay Network provided 18,332 contacts, representing 28% of the total MNC community ambulatory contacts, and an average of 20 contacts per individual client.



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Table 7.5 Mental Health Ambulatory Contacts with Identified Individual Clients by Clinical Network, 2011/12

Age Group Coffs Hastings Macleay Mid North Coast

%

0-11 Years 82 0 7 89 0.1

12-17 years 2,491 3,608 2,530 8,629 13.4

18-64 Years 24,359 11,241 15,273 50,873 78.

65+ Years 2,570 1,807 522 4,899 7.6

TOTAL 29,502 16,656 18,332 64,490 100

Source: North Coast SCI-MHOAT, MNCLHD, 2012



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8 CURRENT ISSUES IN SERVICE DELIVERY

8.1 SERVICE CAPACITY TO MEET CURRENT POPULATION DEMAND The most important current issue for the Mid North Coast in relation to the provision of mental health services, is the provision of sufficient capacity to meet the current population needs, particularly in the Hastings Macleay Clinical Network.

The lack of sufficient capacity in inpatient services is resulting in the flow of acute patients to the Coffs Harbour campus, resulting in flow-on capacity issues at that facility, and an inability to provide local services for youth and elderly patients. The community mental health workforce has not increased commensurately with population and demand growth over the past ten years and enhancement of these resources would enable pressure on acute inpatient beds to be alleviated.

There is also a lack of capacity to provide consultant liaison psychiatry services to the general inpatient wards at the major public hospitals in the Mid North Coast.

More detail on current service gaps is presented below in relation to each of the three major age groups:

8.1.1 Child and Adolescent Mental Health Services

There are no specialist child and adolescent mental health staff operating within MNCLHD Mental Health Services. There is a need for improved access to designated mental health inpatient beds for child and adolescent patients within the Mid North Coast. Children requiring admission to a specialist Child and Adolescent inpatient unit must travel to Lismore. The distance to Lismore, particularly from the Macleay area, which involves a thirteen hour round trip, is not conducive to effective engagement in treatment and involvement of families, many of whom have existing resource and transport issues.

The Nexus unit in Newcastle is available to be used as a tertiary referral service, but it often proves difficult to achieve an admission there.

There is a need to develop enhanced capacity in the provision of early psychosis services for young people (15-24 years).

Community Health Early Childhood and Child & Family Services treat mental health issues in under 12 year olds, however clinical liaison occurs between this service and Mental Health Services.

8.1.2 Acute Adult Mental Health Services

There are insufficient gazetted acute adult inpatient beds in the Hastings Macleay Clinical Network to meet the population demand. This results in overflow of patients to the Coffs Harbour Campus.

The after-hours services are limited and community mental health staffing has not kept pace with the increasing population and community demand over the past ten to fifteen years. The paucity of



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community based case management is leading to a high overall level of unwellness in the community and late detection of illness and disability and extended hospitalisation.

8.1.3 Sub - Acute Mental Health Services

There is a need to provide sub-acute inpatient care for patients discharged from acute inpatient units who require step down inpatient care before returning to reside in the community.

8.1.4 Older Persons Mental Health Services

There is a need for designated older persons mental health services including acute inpatient and sub-acute inpatient beds and access to psycho-geriatric services. Ageing residents are high consumers of health services, particularly chronic and complex care and there is limited access to aged care mental health support. The lack of frail elderly inpatient facilities is an issue as these patients not suitable for admission into acute units.

8.1.5 Consultation Liaison Psychiatry

Consultation Liaison (CL) Psychiatry is a service operating in general hospitals. CL is designed to ensure that medical and nursing staff can obtain appropriate advice when they encounter patients who have problems arising from mental health conditions. It offers consultancy for patients with mental illness admitted to hospital, assessment and treatment of people whose physical illness creates mental health problems, and assessment and treatment of patients with psychosomatic illnesses such as chronic pain. The provision of consultation liaison psychiatry services to general hospital wards is an important function in larger hospitals.

At present consultation liaison (CL) services are provided on a limited, informal basis in the major MNCLHD facilities and there are no formal CL hours for psychiatry in support of the general wards available. There is a need, which will only grow over the next five years, for CL psychiatry services in each of the three major hospital facilities on the Mid North Coast.

8.1.6 Mental Health Support Services

Non-government organisations (NGOs) providing mental health services on the Mid North Coast are also reporting that their services are at capacity in responding to local demand. There is insufficient access to key support services such as supported accommodation. The shortage of affordable housing and supported accommodation is the principal factor delaying the discharge of long stay patient s from acute wards on the Mid North Coast.

8.2 POPULATION GROWTH AND AGEING The population of the Mid North Coast is projected to increase by 22% between 2006 and 2021. The population aged over 65 years is projected to increase by 69% over the same period. These demographic changes will place a substantial additional demand on mental health services within the Mid North Coast.



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The projected increase in the general population, and the elderly population in particular, accentuates the need to address existing capacity of services.

8.3 CONDITION AND/OR FUNCTIONALITY OF INFRASTRUCTURE Coffs Harbour Base Hospital has a recently developed inpatient mental health facility comprising acute and non-acute units. The 30 bed acute unit opened in 2001 and the 20 bed non-acute rehabilitation unit opened in August 2009.

The physical limitations of the acute unit at Kempsey Hospital restricts the role of the unit to non-declared status and the provision of services to voluntary patients only.

The Port Macquarie Mental Health Inpatient Unit does not meet the requirements of NSW Health Facility Guidelines in relation to the seclusion room and the size of the majority of the rooms and other functional spaces. The need for redevelopment of inpatient mental health services at PMBH is recognised and this project features in the top five priorities for MNCLHD in the MNC Asset Strategic Plan.

Ellimatta Lodge in Port Macquarie is a 6 bed residential cottage and previously provided a custodial care service. This model of care is no longer considered appropriate and the facility is now vacant. Is there an alternative role for this facility which is owned by the MNCLHD?

There is a need across all facilities including inpatient and community mental health teams to provide more staff workspaces and client interview rooms with appropriate privacy, particularly for community mental health.

Access to information and communication technology is a major issue for staff. They require greater access to IT support, medical records, including remote access. In the future, the potential impact of electronic health care records will help in this regard. Provision of Discharge Summaries to external services is an ongoing issue.

8.4 INTER-DISTRICT NETWORKING OF SERVICES

There are no inpatient mental health services for Child and Adolescent Mental Health in the Mid North Coast. Patients requiring specialist inpatient care are required to access services at the Child and Adolescent Mental Health Units at Lismore Base Hospital or John Hunter Hospital, Newcastle.

The MNCLHD has a formal agreement with Northern NSW LHD in relation to accessing the Child and Adolescent Mental Health Unit at Lismore but the distance from the Mid North Coast is a significant issue for families.

8.5 MODELS OF CARE

At the Clinical Service Plan Workshop there was recognition amongst the services providing mental health care on the Mid North Coast that all services are finding it difficult to respond effectively to the demands of the present workload and that it is timely to review service models of care.



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There are new models of care that have been introduced, both nationally and internationally, for which lessons can be drawn from. There was broad consensus at the Workshop that, in reviewing models of care, that the emphasis should be on innovation, partnerships and collaboration.

Limited resources make it essential that existing resources are used most effectively. The different government and non-government services have a variety of strengths and that maximum benefit can be gained from services working in partnership, providing mutual support and designing their contributions through a collaborative process that enables service roles to be developed in a complementary fashion.

It is not appropriate, or sustainable, for the MNCLHD Mental Health Service to provide the full range of services that consumers may require. Increasingly, mental health resources are flowing to Commonwealth –funded services and NGOs and these services are developing expertise in their niche roles. The MNCLHD Mental Health Service can maximise their contribution by supporting these services in their role and by identifying how services can best dovetail to provide for the full needs of consumers.

It was agreed that development of new models of care will be designed within the “partners in recovery” framework, and that carers and families need better recognition in care and treatment. There is recognition that, in an environment of constrained resources and increasing demand, MNCLHD should focus on the provision of direct clinical care for people with severe and persistent mental illness, while supporting their service partners such as NGO, Aboriginal Medical services and Commonwealth funded services in the provision of other support services such as supported accommodation and living skills, as described in the Partners in Recovery Framework.

The review and development of service models of care should cover the range of target age groups and services provided and, for the MNC LHD services, should commence with the identification of the core and appropriate role of the MNC LHD in the provision of mental health care in relation to partner services. What is the core business for the public mental health services in the Mid North Coast given the available resources and roles of other mental health service providers including NGOs, private providers and general practitioners?

The development of clinical pathways should clearly delineate roles of respective services and entry and exit points ie clinical pathways for common conditions:

• Entry to services/interfaces – patient flow/streaming of patients. • Stream people away from IPU. • Acute patients. • Alternative paths for patients at ED/IPU points of entry. • Better clinical pathways including discharge planning. • Drug & alcohol links. • ED responsibilities with MH clients. • Establish protocols with service providers to formalise partnerships and accountability

mechanisms • Develop appropriate referral system and supports with Aboriginal Medical Service



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This process could commence with community mental health services. Questions raised at the Planning workshop included:

• How to develop a more responsive service, one that is able to prevent acute admissions?

• What should the staffing profile look like?

• What hours of operation?

• How to dovetail services with those provided by Commonwealth - funded and NGO services?

• Are there any new models of care that could be introduced including long term home based treatment programs and community/ mobile support treatment units?

• With constrained resources to meet growing patient demand, what is the fairest and most appropriate method for Community Mental Health teams in prioritising and managing the needs of new and existing patients?

• What is the best model of care in utilising the available medical workforce?

• To what extent are co-morbidity issues being effectively addressed by current services?

There is also a need to review the models of care for inpatient units including the Rehabilitation Unit. These should cover the development of discharge plans from point of admission. Questions raised at the Planning Workshop included:

• Are there factors which are unnecessarily delaying discharge of patients to the community?

• What service initiatives would address these delays?

• How effectively can services ensure transition of care following an acute care episode?

• What are the most important factors delaying discharge and what are strategies for responding to these?

There is a need to review Specialist Mental Health services for Older People (SHMOPS) service models. In an environment of limited resources including available specialist staff, what are the most effective ways to integrate better with aged care services? How can services achieve better access to the Dementia Behaviour Management Advisory Service (DBMAS) service (particularly in Hastings/ Macleay)? New models of care will need to be established and resources attracted to provide for the growing demand.

Children and young people present an area of high need and these need to be addressed with early intervention and prevention approaches.

These models of care should include the reinstitution of consumer consultants with multiple consumers involved to ensure support and prevent burnout and “tokenism”. The need to create a Consumer Co-ordinator position within MNCLHD has been recognised.



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There is an identified need to develop a greater involvement in prevention and health promotion with regard to mental health. Some programs have been established using a collaborative approach (eg Love Bug) and this is seen as the way forward. Mental Health can look to the way that Drug & Alcohol service has engaged MNC Health Promotion services in its health promotion efforts. These efforts should also cover suicide prevention using the latest framework.

MH-COPES provides feedback data from consumers on their experience with services which can be used to provide feedback and information on greatest areas for improvement.

How can small services collaborate with other services such as NGO and Commonwealth funded services so that they can better access experts and better meet client’s needs?

8.6 WORKFORCE

A sustainable workforce of appropriately qualified staff is essential to ensure the delivery of quality mental health services. Nationally, there is a shortage of skilled mental health nursing workforce and the existing workforce is ageing. Locally, there is a shortage of psychiatrists. There is a need to maintain a trained workforce and avoid burnout by ensuring manageable workload.

There is an identified need to provide a designated nurse educator position to assist in the training and education needs of local nursing staff. Access to allied health staffing, (notably social work and clinical psychology)is limited for mental health services.

There is a need to oversee the development of a supported and skilled Aboriginal Workforce.

Strategies will need to be developed and implemented to ensure the recruitment and retention of an adequate workforce to provide the projected levels of future mental health services. These could include working with local tertiary education institutions in the development of scholarships, training places and design of packages to attract staff to the Mid North Coast.

8.7 ACCESS TO SERVICES AND TRANSPORT OF PATIENTS

Access and transport of patients with mental health issues can be an issue in rural locations due to the geographic distance between services. In some areas, notably Kempsey, a large proportion of the population do not have access to transport. Public transport services are limited and in the Hastings area the Community Mental Health Team is providing transport for clients in areas such as Wauchope, Laurieton, Bellbrook, Dorrigo, Ebor, Halfway Creek by case managers where time could be spent providing direct clinical care.

In particular, there are issues at Kempsey District Hospital for the safe and secure management of presentations given the lack of declared beds in the Emergency Department and Mental Health Unit. The Ambulance Service at Kempsey won’t transfer patients after 8.30pm, and even transport in business hours can be difficult.



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8.8 SERVICES FOR ABORIGINAL POPULATION

There is a significant local Aboriginal population requiring culturally appropriate mental health services. Aboriginal people represent approximately 5% of the total MNC population and over 10% in parts of MNC such as Kempsey. In the Macleay Valley, over 20% of child and adolescent population are Aboriginal. Indigenous clients comprised 10% of the total active client base of community ambulatory clients currently being seen by Mid North Coast community mental health teams in 2012. This community has unique and special needs in regard to mental health services. Despite the significant need there is only one full-time aboriginal identified mental health clinician in the LHD and three trainees who can only work under supervision. There is a need to create more positions across a range of disciplines to support the Aboriginal community eg include Clinical, Aboriginal Health Officers and frontline administration staff .

There is a need to build culturally safe and competent services with staff appropriately trained in cultural awareness.

8.9 SERVICES FOR REFUGEE COMMUNITY

The Mid North Coast is home to a growing population of people from culturally and linguistically diverse communities including recent immigrants from countries such as the Sudan, Burma and Democratic Republic of Congo. Many are refugees who have experience violence, torture and trauma and some may have left family members in their country of origin and are now unable to return26. Members of these communities may have complex needs and culturally different beliefs relating to how they perceive and describe illness and how they access treatment and participate in recommended recovery programs.

There is a recognised need to develop culturally appropriate services to respond to their specific needs and to develop pathways to care, training for service providers and access to interpreters.

26 Transcultural Mental Health (2010) Transcultural Rural and Remote Outreach Project



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9 PROJECTED DEMAND

The Mental Health Clinical Care and Prevention (MH-CCP) methodology is the recognised tool for both comparing current mental health resources against estimated prevalence in the community, and for projecting future service requirements, in NSW27. The methodology was described in Section 5.4.

The Mental Health Clinical Care and Prevention model, was originally developed in 2001, and has recently been reviewed and an updated methodology provided by the Mental Health and Drug & Alcohol Office in 2012 has been used for the purpose of developing estimates and projections of prevalence rates and resource requirements for the MNCLHD Mental Health Clinical Services Plan.

The MH-CCP presents age-specific prevalence estimates for varying levels of severity of mental health risks and disorders across the lifespan. For the purpose of informing the Mid North Coast Mental Health Plan, the four age groups are used:

• Children (age 5-11 years)

• Adolescents (age 12-17 years)

• Adult (age 18-64 years)

• Older People (age 65 years and over)

Overall, the MH-CCP estimates that, for the Mid North Coast population of 213,809 people in 2011, over a 12 month period that:

35,492 people, or 16.6% of the population, would experience a clinically diagnosable mental disorder (refer Table 5.3) ;

9,621 people, or 4.5% of the population, would experience moderate to severe problems that impair function and may be persistent and 20,525 people, or 9.6% of the population, would experience significant but milder problems ;

5,345 people, or 2.5% of the population, would experience severe mental health problems, including psychotic disorders (ie schizophrenia, bipolar disorder), severe depression and anxiety disorders. People with these conditions form the primary target group for MNCLHD Mental Health Services.

The estimated prevalence is based on the average prevalence for NSW as a whole. Some parts of NSW would have a higher burden of disease as a result of demographic and socio-economic factors and historical factors such as the “drift” of people with mental illness to surrounding areas of the former Fifth Schedule mental health inpatient facilities.

27 Mental Health and Drug & Alcohol Office, NSW (2001) Mental Health Clinical Care and Prevention Model Version 1.11 a population mental health model; Ministry of Health (2012) Mental Health Clinical Care and Prevention Model, 2010



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9.1 CURRENT CAPACITY MEASURED AGAINST MH-CCP

The MH-CCP also provides an estimate of capacity requirements (inpatient beds, workforce FTE) to provide services for this estimated level of prevalence, by target age group. Service requirements are presented in the tables below at 100% of MH-CCP.

9.1.1 Inpatient Beds The estimated acute mental health inpatient bed numbers required for the Mid North Coast population based on the estimated prevalence in the MH-CCP are presented, by age group, in Table 9.1 below, compared to the current available beds in designated inpatient units.

Table 9.1 Current Acute Bed Numbers and MH-CCP Estimated Requirements, 2011

Age Group Current Bed Numbers MH-CCP (100%)

2011

Child (0-11 years)* Mid North Coast

0

0

Adolescents (12-17)* Mid North Coast

0

2


42**

38


0

13


42

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*Child and Adolescent Beds for Mid North Coast currently provided within Lismore Base Hospital CAMHU ** Does not include 10 non-gazetted beds at Kempsey District Hospital. Source: NSW Health Population Projection Series 1.2009, Department of Planning & Statewide Service Development Branch, NSW Health, March 2009 & Estimated Residential Population at 30 June 2006, NSW (3235.0), Australian Bureau of Statistics, July 2007, MHDAO (2012) MH-CCP 2010 The comparison of current acute inpatient mental health beds in the Mid North Coast LHD against the MH-CCP benchmarks indicates that, overall, across all age groups, the LHD has an insufficient number compared to the beds estimated using the MH-CCP, ie, 42 beds compared to the 53 beds estimated at 100% of MH-CCP requirements. The 38 beds estimated using the MH-CCP include 5 beds for Early Intervention and Prevention for the 18-24 year age group.

Mid North Coast would appear from this analysis to be under-resourced in terms of acute adult mental health inpatient beds. It should be noted, however, that there are 10 adult beds in Kempsey District Hospital that are not declared under the Mental Health Act 2007, and therefore not able to accept involuntary mental health patients and operate as an acute unit. At present there are no designated inpatient mental health beds for older persons in the Mid North Coast LHD. The MH-CCP estimates a need for 13 beds in 2011 for this age group.



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The 13 beds estimated by the MH-CCP for acute inpatient care for older persons includes 4 beds in general adult acute mental health units and 9 beds in designated Specialist Mental Health Services for Older People (SMHSOP) units. At present approximately 7 per cent of acute adult mental health inpatient beds are being used to admit older patients. The admission of frail older people and people with dementia to acute adult inpatient units is not appropriate however, and there is a demonstrated need for a designated mental health inpatient unit for older persons on the Mid North Coast.

The MH-CCP methodology indicates the need for around two beds for the adolescent population of Mid North Coast (12-17 years). At present the Lismore Base Child and Adolescent Mental Health Unit has 8 beds and is funded to provide this service for the Mid North Coast.

The estimated non-acute mental health inpatient bed numbers required for the Mid North Coast population based on the estimated prevalence in the MH-CCP are presented, by age group, in Table 9.2 below, compared to the current available beds in the designated inpatient unit.

Table 9.2 Current Non-Acute Bed Numbers and MH-CCP Estimated Requirements, 2011

Age Group Current Bed Numbers MH-CCP (100%)

2011


8*

7


0

7


8*

14

* Represents 40% of the NC Rehabilitation Unit beds. The catchment for this unit covers MNC and Northern NSW LHDs Source: NSW Health Population Projection Series 1.2009, Department of Planning & Statewide Service Development Branch, NSW Health, March 2009 & Estimated Residential Population at 30 June 2006, NSW (3235.0), Australian Bureau of Statistics, July 2007, MHDAO (2012) MH-CCP 2010 The MH-CCP benchmarks indicate a need for 14 non-acute adult inpatient beds to provide for the mental health needs of the Mid North Coast population.

The 20 bed North Coast Rehabilitation Unit at Coffs Harbour Health Campus was built to provide for the Mid North Coast (40%) and Northern NSW (60%) population. In 2010/11, 70% of separations for this Unit were for residents of Mid North Coast and 26% for residents of Northern NSW. The total population need for non-acute adult inpatient beds across both Mid North Coast and Northern NSW in 2011 is 32 beds in 2011 for adult and older persons combined.

There are no designated non-acute inpatient beds for older persons on the Mid North Coast. The MH-CCP indicates a population need for 7 beds in 2011.These include 5 Transitional Behavioural Assessment and Intervention Service (TBASIS) beds.



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9.1.2 Long Stay Patients There are a small number of people whose mental health condition is such that they are unable to function in the community. These people require extended long stay in one of the residential mental health facilities in NSW. These include long stay / extended care units at Bloomfield Hospital in Orange, Macquarie Hospital, Morriset Hospital and Cumberland Hospital at Westmead.

There are a small number of Mid North Coast residents who are currently admitted in these Statewide facilities and there are also patients who are admitted to mental health units within the Mid North Coast for extended periods in excess of the standard length of stay in these acute or non-acute units.

The MH-CCP methodology indicates the need for 16 beds for adults (6 beds rehabilitation, 10 beds extended care) and 5 beds for older persons for Very Long Stay mental health inpatient care. The MNCLHD does not intend to develop local facilities for the provision of Very Long Stay mental health inpatient care. Such care will continue to be provided within the designated Statewide units to which MNCLHD services are able to achieve timely access for their patients if required.

9.1.3 Workforce The estimated workforce requirements in 2011 across ambulatory care and acute inpatient settings, as estimated using the MH-CCP is presented in Table 9.3 below in comparison to current staff levels.

Table 9.3 Current Ambulatory & Acute Inpatient Workforce and MH-CCP Estimated Requirements, 2011

Age Group Current Workforce (FTE)

MH-CCP (100%) 2011

Ambulatory Mental Health Children (0-11 years) Mid North Coast

0

18

Adolescents (12-17 years) Mid North Coast

12.74

21


59

93


5.1

26

TOTAL AMBULATORY Mid North Coast

76.84

158.0

Acute Inpatient Mental Health* Adults Mid North Coast

102.8

69


0

25

TOTAL INPATIENT Mid North Coast

102.8

94

*Child and Adolescent Beds for Mid North Coast currently provided within Lismore Base Hospital CAMHU



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Source: NSW Health Population Projection Series 1.2009, Department of Planning & Statewide Service Development Branch, NSW Health, March 2009 & Estimated Residential Population at 30 June 2006, NSW (3235.0), Australian Bureau of Statistics, July 2007, MHDAO (2012) MH-CCP 2010

The latest MH-CCP data indicates a significant understaffing in ambulatory care mental health programs on the Mid North Coast and that current inpatient staffing levels are closer to the estimated MH-CCP levels. The MH-CCP estimates a requirement for 69 FTE clinical staff in adult inpatient units. This includes 9 FTE staff for Early Intervention and Prevention for the 18-24 years age group. In addition, of the 25 FTE clinical staff estimated for inpatient care of older people, 8 FTE are for the care of older persons in the general adult acute units. Overall, the 94 FTE staff estimated using MH-CCP is close to the current 102.8 FTE, notwithstanding variations in the mix of positions across the various target age groups. As with the bed capacity analysis, the lack of resources for mental health services for older persons is offset by the higher resource levels for adult teams. The MH-CCP estimates indicate that the staffing levels in ambulatory settings are significantly less than those estimated by MH-CCP. The MH-CCP estimate of 158 FTE ambulatory care staff is inclusive of a number of different programs, some of which are new services that have not been fully implemented as yet. The 21 FTE clinical staff for the 12-17 years age group includes 17 staff providing ambulatory care only, including 13 staff covering the ambulatory care of children with severe mental health conditions, and 4 staff providing ambulatory care around inpatient episodes including consultation liaison to patients in general beds, Early Intervention and Prevention and other acute admissions. The 93 FTE estimated clinical staff for adult ambulatory care includes 61 FTE staff providing ambulatory care only, including 33 FTE staff providing ambulatory care for adults with severe mental health conditions and 16 staff providing for adults with moderate mental health conditions. There are a further 29 FTE clinical staff providing ambulatory care around inpatient episodes of care for adult patients. The additional 3 ambulatory care FTE are to provide ambulatory care support to programs such as HASI. The 26 FTE estimated clinical staff for older persons ambulatory care includes 11 FTE providing ambulatory care only, 7 FTE providing ambulatory care in support of inpatient episodes of care and 8 FTE providing ambulatory support to programs such as HASI and residents of residential aged care facilities.

9.1.4 Consultation Liaison The provision of Consultation Liaison (CL) Psychiatry services to ensure that medical and nursing staff in general hospital wards can obtain appropriate advice when they encounter patients who have problems arising from mental health conditions is covered separately in MH-CCP to the requirement for clinical mental health staffing in designated mental health units as indicated in section 9.1.3 above.



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The latest MH-CCP indicates a need for 4.0 FTE clinical staff to provide CL services to patients in general beds and emergency departments for adult patients, and a further 2.0 FTE for older persons, in 2011 for the Mid North Coast LHD. At present there are 3.0 FTE CNC positions (one in each of the three major hospitals) located in the Emergency Departments providing CL services. There are no formal hours available for the provision of CL psychiatry in any of the MNC general hospitals. Any provision of CL psychiatry services occurs on an ad hoc basis. In planning for the future, there is clearly a need to develop some level of capacity to provide CL psychiatry services in each of the three major general hospitals on the Mid North Coast.

9.2 PROJECTED CAPACITY REQUIREMENTS Projected bed requirements for acute services are presented in table 9.5 below. This table indicates the number of beds required in 2016 and 2021 using the MH-CCP 2010 (2012) methodology, at 100% of estimated levels.

Table 9.4 Current and Projected Acute Bed Numbers and MH-CCP Estimated Requirements, 2011-2021

Age Group Current Bed Numbers

MH-CCP 2010 (100%)

2012

2011

2016

2021

Child (0-11 years) 0 0 0 0 Adolescents (12-17)* Mid North Coast

0

2

2

2


42**

38

39

40


0

13

16

19


42

53

57

61

*Child and Adolescent Beds for Mid North Coast currently provided within Lismore Base Hospital CAMHU ** Does not Include 10 non-gazetted acute beds at Kempsey District Hospital Source: NSW Health Population Projection Series 1.2009, Department of Planning & Statewide Service Development Branch, NSW Health, March 2009 & Estimated Residential Population at 30 June 2006, NSW (3235.0), Australian Bureau of Statistics, July 2007, MHDAO (2012) MH-CCP 2010

The estimation of inpatient bed requirements based on the projected population growth and ageing in the Mid North Coast indicates the need for a substantial increase in adult acute beds, from the current 42 to 61 beds in 2021. The major increase in bed capacity requirements is for acute inpatient beds for older persons. The MH-CCP indicates the need for 19 beds which includes 13 SMHSOP beds and 6 beds for older persons in general adult acute units. At present there are no designated inpatient mental health beds for older persons in the Mid North Coast LHD. In respect of non-acute bed requirements, the need for non-acute beds by the Mid North Coast population is projected to increase to 17 in 2021, representing an increase of 9 from the 8 currently available. This would provide for the non-acute bed needs for older persons estimated at 10 by



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2021, as indicated in Table 9.5 below. It should be noted that these beds are exclusive of Very Long Stay bed requirements for rehabilitation and extended care.

Table 9.5 Current and Projected Non-Acute Bed Numbers and MH-CCP Estimated Requirements, 2011

Age Group Current Bed Numbers

MH-CCP 2010 (100%)

2012

2011

2016

2021


8*

7

7

7


0

7

8

10


8

14

15

17

* Represents 40% of the NC Rehabilitation Unit beds. The catchment for this unit covers MNC and Northern NSW LHDs Source: NSW Health Population Projection Series 1.2009, Department of Planning & Statewide Service Development Branch, NSW Health, March 2009 & Estimated Residential Population at 30 June 2006, NSW (3235.0), Australian Bureau of Statistics, July 2007, MHDAO (2012) MH-CCP 2010 The MH-CCP estimates indicate that the projected requirement of 17 beds for the Mid North Coast population alone in 2021 is 9 more than the current Mid North Coast allocation of the North Coast Rehabilitation Unit at Coffs Harbour. The total population need for non-acute adult inpatient beds across both Mid North Coast and Northern NSW in 2011 is 32 beds in 2011 for adult and older persons combined, increasing to 39 beds in 2021.



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10 FUTURE ROLE AND SERVICE

REQUIREMENTS

Over the next ten years to 2021, Mid North Coast LHD Mental Health services will continue to be managed and networked on a district-wide basis. Such networking provides the critical mass to provide for the full range of services of secondary level mental health services, both hospital inpatient and ambulatory community based services, and tertiary services such as the non-acute rehabilitation inpatient unit at Coffs Harbour Campus. Models of care are reviewed, clinical services are planned and workforce strategies developed for the whole of the Mid North Coast by the LHD Mental Health Service. Within the LHD, the Hastings Macleay and Coffs Harbour Clinical Networks will manage the provision of hospital and ambulatory services for the catchment population served by these networks.

Section 10 describes, in broad terms the future roles of the key MNCLHD Mental Health Services that will be required to deliver the projected level of services to the community over the next five to ten years. The anticipated review of Models of Care will be expected to enable services to work more effectively, particularly in collaboration with each other and with Commonwealth funded and NGO services.

10.1 COFFS HARBOUR CLINICAL NETWORK

The analysis in Chapter 9 has indicated that, in terms of inpatient acute adult mental health beds, the Coffs Harbour Clinical Network has sufficient capacity to provide for the projected population needs to 2021 and beyond for the Coffs Harbour, Bellingen and Nambucca LGAs.

The North Coast Rehabilitation Unit will continue to provide for the needs of a tertiary population catchment covering the Mid North Coast and Northern NSW LHDs for the foreseeable future. In the longer term, the MH-CCP indicates that additional non-acute inpatient beds will be needed within this broader population catchment.

Mental health staffing within the ambulatory community health teams has not increased commensurately with population growth and in comparison to inpatient services over the past ten years. The MH-CCP data suggests that staffing levels are below the projected population requirements for the range of early intervention, acute and extended care services.

The planning consultations conducted as part of the process of developing the Clinical service Plan have identified the need to review current models of care operating across the LHD and particularly, in respect of how services are collaborating and developing complementary service partnerships with Commonwealth-funded and NGO mental health services.



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10.2 HASTINGS MACLEAY CLINICAL NETWORK

The analysis of current inpatient capacity against population needs has indicated the need for additional, purpose-built inpatient capacity for mental health services in the Hastings Macleay Clinical Network. In terms of the current available inpatient bed capacity in Hastings Macleay:

• There are only 12 acute adult beds for involuntary patients within the Network, and these beds at Port Macquarie Base Hospital do not meet Health Facility Guidelines in relation to a number of design aspects;

• The ten beds at Kempsey Hospital do not permit the admission of gazetted or involuntary patients, requiring that such patients must be transferred to the Port Macquarie or Coffs Harbour acute adult inpatient units;

• These two acute adult units are of sub-optimal size. The optimal size for an acute adult unit for efficiency of staffing and operation is 18-35 beds;28

• There are no designated inpatient beds for older persons mental health care within the Mid North Coast LHD;

• Access to the specialist child and adolescent beds located in Lismore is problematic due to the distance and round trip of over 13 hours for patients and their families.

Similar to the Coffs Harbour Clinical Network the staffing in community mental health teams has not increased to match growing population demands over the past ten years, and there is a recognised need to review and update operating models of care for these mental health services.

There is clearly a need on the Mid North Coast to develop an improved range of options for the care of people with more severe psychogeriatric disorders that result in behaviours that place either themselves or others at risk, as well as for people with less severe psychogeriatric disorders including the frail elderly who are not appropriate for admission to acute adult units. The development of service options for people with psychogeriatric disorders will involve collaboration across primary health, aged care and mental health service sectors. The development of a designated mental health inpatient unit for older persons on the Mid North Coast should be considered.

28 Australian Health Infrastructure (2012) Australian Health facility Guidelines: Adult Acute Mental Health Inpatient Unit, Rev 5.0, 11 April 2012



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10.3 PROJECTED SERVICE REQUIREMENTS

10.3.1 Consolidated Acute Adult Unit for Hastings Macleay Clinical Network

The current acute adult inpatient units within Hastings Macleay Clinical Network are sub-optimally sized, at 12 and 10 beds respectively, for PMBH and Kempsey Hospital. As indicated above, the most efficient size is around 18-35 beds. The larger sized unit provides a critical mass of service for both staffing and general operation. Given the design issues for both the PMBH and KH inpatient units, it is appropriate to plan for the development of a new purpose designed, acute mental health unit of 25 beds in Hastings Macleay.

This Unit should be developed on the PMBH campus which has space for such a development, as an extension and redevelopment of the current mental health inpatient unit. The Unit would be designed as a gazetted unit to provide for involuntary patients. The proposed unit would provide 19 acute adult inpatient beds including 4 intensive care beds and 6 older persons acute inpatient beds.

The function of the unit is to provide, in a safe and therapeutic environment, appropriate facilities for the reception, assessment, admission, diagnosis, observation, treatment and recovery of often acutely unwell consumers, presenting with known or suspected psychiatric conditions and behavioural disorders. Consumers may be admitted on a voluntary or involuntary basis. Consumers may be agitated, aggressive and potentially a risk to themselves or others. Therefore the environment should be conducive to the management of complex behaviours offering the capacity for observation of consumers by staff, discreet security, and where necessary temporary containment. However, this should be achieved with a therapeutic focus so that while necessary measures for safety and security are in place, they are non-intrusive and do not convey a custodial ambience. In the meantime, given the current adequacy of inpatient beds, the Mental Health Service should ensure the best use of these beds at PMBH through efficient bed management and discharge planning processes. By 2016, an additional five beds will be needed. If there is an opportunity to expand to this number over the next three years - and if the likelihood of a new 25-bed unit is not likely to be achieved within this timeframe - it should be taken in PMBH in a way that provides contiguity with Ward 1A. Such beds could fill existing gaps in the younger or older age groups. A model for the younger age group might consider the new ways of thinking about youth as the 12-24 age group, and the service consistency this might provide for clinical linking with NGOs such as Headspace.

10.3.2 Older Persons Inpatient Unit

There is a need to develop inpatient facilities to provide for the growing population of older persons on the Mid North Coast who will require treatment for acute psychogeriatric disorders.

The primary focus of such a service is restoring the health of older persons with a psychiatric disorder to an optimal degree of mental function by addressing the patient’s psychological, physical and social needs. The MH-CCP indicates the need for thirteen Specialist Mental Health Services for



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Older Persons (SMHSOP) beds to meet the needs of the Mid North Coast in 2021, and six beds for older persons within adult acute units.

The role and function of a SMHSOP Acute Inpatient Unit (AIU) including a description of target population, interventions and service models and practice is provided in the SMHSOP Acute Inpatient Unit Model of Care Project Report29. This report explains that the AIU will be part of the continuum of care that also includes mental health promotion, prevention and early intervention, ambulatory/community services, sub-acute and non-acute inpatient care and community residential care.

The primary functions of the AIU include: assessment; clinical review and care planning; management of acute risk; treatment focused on clinical symptom reduction with a reasonable expectation of improvement in the short term; and transfer of care from the unit as soon as feasible. Discharge to the usual place of residence is the primary goal of management, but transfer to an alternative longer term facility such as an aged care facility, extended care, specialised residential aged care facility, or inpatient unit, may be required.

These units should be able to manage both voluntary and involuntary patients under the Mental Health Act.

The NSW SMHSOP Service Plan30 defines the SMHSOP target population as older people (65 years and over) who:

• Develop, or are at high risk of developing, a mental health disorder at the age of 65 years and over, such as depression, acute psychosis, anxiety, late onset schizophrenia or a severe adjustment disorder

• Have had a lifelong or recurring mental illness, and now experience age-related problems causing significant functional disability (i.e. become ‘functionally old’)

• Have had a prior mental health problem but have not seen a specialist mental health service for at least five years and now have a recurrence of their illness or disorder that can be optimally managed by SMHSOP

• Present with severe behavioural or psychiatric symptoms associated with dementia (BPSD); or other long-standing organic brain disorder and would be optimally managed with input from SMHSOP. This may include people who are deemed at risk of harm to themselves or to others.

In National Older Person Mental Health Benchmarking Forums the average length of stay in 2006/07 was 45 days.

In terms of ideal size, smaller clusters are more appropriate for older persons mental health units, as older persons are more prone to confusion, particularly in the case of patients with moderate

29 Ministry of Health (2012) SMHSOP Acute Inpatient Unit Model of Care Project Report 30 Ministry of Health (2006) Specialist Mental Health Services for Older People (SMHSOP) - NSW Service Plan - 2005-2015



75

dementia. Accordingly units of between 8-12 beds are recommended31. Larger facilities may be more confusing for older consumers and high quality care is easier to provide in small groups. Groups of eight beds have been found to be sufficiently small for the care of mobile, confused and disturbed older people. An 18-24 bed unit, consisting of multiple clusters, is considered to be efficient from a staffing and budget perspective32. The AIU Project Report makes it clear that, in order to provide basic services for optimal treatment, new SMHSOP AIUs need to develop effective partnerships with a range of other services, particularly SMHSOP community teams, aged care services and adult mental health services. Functional relationships with SMHSOP community teams are fundamental and the AIU and its models of care must support integrated service provision across inpatient, community and residential settings. In developing a SMHSOP acute inpatient capacity within MNC LHD, two options were discussed. One option is to consolidate the beds into a single unit. This would provide efficiencies from a staffing and budget perspective in catering for whole of LHD requirements. Such a unit could be 12-16 beds in size. There are arguments in favour of locating such a unit at PMBH. This would provide easy access to the clinical services of a Base Hospital providing services at role delineation Level 5 including ECT, aged care services and acute medical services. The latter is important as older people with mental health disorders also have high rates of physical health conditions.

The second option is to take the opportunity that would arise from consolidating acute mental health inpatient services in Hastings Macleay at PMBH as described in section 10.3.1 above. This would enable the development of an 8-10 bed SMHSOP AIU at Kempsey Hospital, after suitable modification of the current 10 bed unit at KDH. Physical modification of the existing space could also resolve the physical issues that inhibit the admission of involuntary patients.

A further six acute older persons mental health inpatient beds would also be incorporated in the proposed PMBH redevelopment. If additional inpatient beds for older persons are required in the future, over and above these 14 beds, consideration could be given to redesignating 6 of the 30 acute adult beds at Coffs Harbour Acute Mental Health Unit as SMHSOPs beds.

This latter option is the preferred option identified in the CSP. In either option, the proposed units would provide for the needs of the whole of the MNC LHD catchment.

The proposed development of a designated SMHSOP inpatient unit within MNC LHD will require the recruitment of a Psycho-Geriatrician to provide clinical care at this unit and to provide leadership for the provision of older persons mental health services in the MNCLHD including outreach services to the other major hospital facilities and community health services.

10.3.3 Maintain Acute Adult and Non-Acute Units at Coffs Harbour

The Coffs Harbour Health Campus will continue to provide 30 acute adult beds, primarily for the Coffs Harbour Clinical Network population, while also catering for occasional flows from Hastings

31 Australian Health Infrastructure (2012) Australian Health facility Guidelines: Older Persons Acute Mental Health Inpatient Unit, Rev 1.0, 31 May 2012 32 Ministry of Health (2012) SMHSOP Acute Inpatient Unit Model of Care Project Report



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Macleay, and 20 non-acute beds for the tertiary catchment of Mid North Coast and Northern NSW LHDs.

In the longer term, these 20 non-acute beds will not be sufficient to provide for the needs of this population catchment. The MH-CCP indicates a need for around 39 non-acute beds to provide for the estimated population need in 2021 across both Mid North Coast and Northern NSW. In the longer term planning for an additional 20 bed unit is warranted, most logically within Northern NSW LHD.

10.3.4 Enhance Capacity of Community Mental Health Teams

The Community Mental Health teams in both the Coffs Harbour and Hasting Macleay Clinical Networks have not been significantly increased in staffing capacity over the past ten years. These services are struggling to provide case management and therapeutic interventions for catchment populations that have increased in size and complexity over this period.

The MH-CCP (2001) indicated that the current ambulatory mental health staffing in MNCLHD was below the estimated requirement for the population size. The revised MH-CCP 2010 (2012) incorporates new service programs in the ambulatory care component that are yet to be fully implemented. Nevertheless, these estimated requirements as presented in Table 9.3 are significantly greater than the current staffing establishment. Estimating the future required ambulatory mental health staffing at 80% of the MH-CCP population requirement provides a figure of 112 FTE, 35 FTE greater than the current 76.4 FTE.

There is a justified need to enhance the staffing capacity for both Hastings Macleay and Coffs Harbour Community Mental Health Teams, by at least 6-10 FTE per Network. Enhancement of ambulatory mental health staffing will support earlier detection of illness, earlier intervention and prevention of escalating unwellness and hospitalisations.

The composition and mix of additional staffing would be best determined following the proposed review of service models of care, but there is a clear need to enhance ambulatory positions providing older persons care and support.

The additional staff that will be expected to be recruited over the next five to ten years will increase the need, which exists at present for adequate accommodation for both office space and interview rooms with appropriate levels of privacy.

10.3.5 Strengthen Links with Aged Care Services

At present there are only five clinical staff in Mid North Coast LHD Mental Health Services for Older People (3.05 FTE in Hastings Macleay Clinical Network and 2.05 FTE in Coffs Harbour Clinical Network). This does not provide an effective critical mass for responding to the needs of people with psychogeriatric disorders, for whom the population demand is already considerable, and will continue to grow over the next ten years and beyond.

Mid North Coast LHD Aged Care Services also provide a range of services for people with psychogeriatric disorders and there is overlap and a lack of clarity in the provision of services. Aged Care Services employ a number of clinical staff including psychogeriatricians and nursing staff



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including psychogeriatric CNCs in both Hastings Macleay and Coffs Harbour Clinical Networks. These staff provide regular clinics and support including assessment, coordination of home-based support services and referral.

There is a need to both enhance the capacity of hospital and community based older persons mental health services and to achieve a better integration of mental health services for older persons across Mid North Coast Aged Care and Mental Health Services. The recommended development of a designated SMHSOPs inpatient unit at Kempsey Hospital will require the recruitment of a Psycho-Geriatrician to provide clinical care at this unit and to provide leadership for the provision of older persons mental health services in the MNCLHD including outreach services to PMBH and CHHC.

There is a lack of designated inpatient services for older persons with dementia and psychogeriatric conditions but this can be partially addressed through the provision of specialist support to residential aged care facilities (RACF) on the Mid North Coast. There is a growth of new RACF developments in the major urban centres of the MNC and these facilities have been designed to accommodate older persons with high needs. Many of these facilities have vacant beds and the only reason they are not accepting high needs older people at present is the lack of skills and expertise in management of behaviours.

A new model of care that could be developed is the provision of inreach support from the community mental health teams to residential aged care facilities. The provision of nursing support from the Mental Health Services for Older Persons team to the RACF could enable the RACF to develop expertise and improved confidence in caring for older people with dementia and psychogeriatric conditions. The development of this option would require an enhancement of current staffing in the SMHSOPs teams with positions for experienced nursing staff capable of providing specialist assessment, consultation liaison, co-ordination and skills development. It would provide an effective alternative to the establishment of inpatient services for older people with dementia and psychogeriatric conditions, and in so doing, address a key service gap.

10.3.6 Greater Use of Telehealth

Given the difficulties in providing adequate specialist medical support locally in a rural local health district, there should be an expanded use of teleconference consultations for specialist services such as Child and Adolescent, Pyschogeriatric, forensic, eating disorders and personality disorders. Such links with tertiary units in Sydney and other major centres could cover both assessment and, potentially, treatment services.

10.3.7 ECT

There is a need to reintroduce the provision of electroconvulsive therapy (ECT) at PMBH. Timely provision of ECT for patients such as those with psychotic depression will improve patient outcomes and reduce length of stay.

10.3.8 Services for Young People

Despite the difficulties in accessing specialist adolescent mental health beds at Lismore, the projected demand is equivalent to two inpatient beds for this service for the Mid North Coast population and it is therefore not appropriate to consider the development of specialist inpatient



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beds. For this reason it is important that the Mid North Coast focusses on the development of effective early intervention and prevention services and to have good pathways to specialist services in place when escalation is required.

There is a need to develop enhanced capacity in the provision of early psychosis services for young people (15-24 years). There is greater recognition of the need to provide earlier detection of psychosis in young people and to provide early intervention services including information, assessment and treatment.

The location of current services in the proximity of acute adult inpatient services is not considered to be ideal as this can be a confronting environment for young people and parents experiencing a first episode of mental illness. It is appropriate to provide services from a more child friendly and family focussed environment.

For this reason, in Port Macquarie, the recently vacated Ellimatta Lodge should be considered as a potential location to provide day programs and outpatient clinics for Youth and Family Services in the Hastings Macleay Clinical Network. The relocation of the Port Macquarie Mental Health Service for Young People from PMBH to Morton St would have some flow-on impacts that would need to be managed, including access of Youth and Family clinical staff to peer support and access for Child and Family Services at PMBH to specialist mental health consultation.

The potential development of an Early Psychosis Prevention and Intervention Centre (EPPIC) at Coffs Harbour provides an opportunity to co-locate the Coffs Harbour Clinical Network Mental Health Services for Young People team.

10.3.9 Involvement of Consumers

There is national recognition of the need to involve consumers and carers in the planning, delivery and evaluation of mental health services. While the former North Coast Area Health service was the only AHS not to have a formal consumer participation model including a consumer / carer workforce, progress has been made with the development of the Mental Health Consumer Perception and Experiences of Services (MH-CoPES) system of feedback.

The Mid North Coast LHD has now indicated its support for the establishment of a Mental Health Consumer Partnerships Coordinator. This position would be part of the MNCLHD Mental Health Executive and would be involved at a strategic and management level in assisting the Mental Health Service to become more consumer recovery focused. The successful applicant for this position will have a lived experience of mental illness and an understanding of the issues faced by people with a mental illness.

10.3.10 Review of Models of Care

As recognised at the national level, there needs to be a commitment to regularly reviewing whether existing services and practices and the way people do things are still the best way33. Good practice across mental health and support services should be based on evidence and services need to be

33 National Mental Health Commission (2012) A Contributing Life: the 2012 National Report Card



79

effective, efficient, provide value and demonstrate improvement in mental health outcomes for consumers and their families.

There was general agreement at the Planning Workshop held in October that it was timely to review the service models of care currently in operation across inpatient and ambulatory settings, and that the development of the MNCLHD Mental Health Plan represented a good opportunity to commence this process. There was also a strong consensus at the Workshop that this should occur as part of an ongoing and overarching consortium of service providers involving MNCLHD Mental Health Services and key partners including NGOs, Commonwealth funded services such as Medicare Locals and Headspace, ACCHCs, and that, in reviewing models of care the emphasis should be on innovation, partnerships and collaboration within the context of the “partners in recovery” framework. The role of carers and families should be acknowledged and strengthened.

Many of the existing models of care were designed some time ago and consumer needs have changed and the implementation of service models against best practice may be variable in different locations. There are new models of care that have been introduced and evaluated, both nationally and internationally, and some of these may offer improved consumer outcomes and be suitable for the Mid North Coast.

The review and development of service models of care should cover the range of target age groups and services provided and, for the MNC LHD services, should commence with the identification of the core and appropriate role of the MNC LHD in the provision of mental health care in relation to partner services. The role, and core business, for the public mental health services in the Mid North Coast should be clearly demarcated within the framework of services and the roles of other mental health service providers including NGOs, private providers and general practitioners.

It was recognised that the MNCLHD Mental Health service is faced with constrained resources and growing pressures of demand in the community, and therefore their priority should be the provision of direct clinical care for people with severe and persistent mental illness, and provide support to NGO and other services providing support services such as supported accommodation and living skills, as described in the Partners in Recovery Framework.

As a result some current non-clinical activities may need to be transferred to other organisations. An example is the day living skills programs currently provided out of Karawa Cottage in Port Macquarie. Services such as these could be more appropriately provided by an NGO with skills and expertise in this area.

A key focus for the Mid North Coast should be the development of increased supported accommodation which would address on of the major delays in discharge for long stay patients in acute wards.

The development of clinical pathways should clearly delineate roles of respective services and entry and exit points, including improved discharge planning ie clinical pathways for common conditions. There is an opportunity to involve consumers in the design of new models of care through the input of the proposed Consumer Partnerships Coordinator.



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The proposed Consortium of Service Providers would have an ongoing role in overseeing the implementation of new models of care and evaluation of service standards and outcomes.

10.3.11 Advocate for Improved Access to Rehabilitation and Supported Accommodation

Rehabilitation services such as vocational training and living skills and other support services promote recovery across all settings – inpatient to community – to enable consumers to live their life to the fullest potential, avoiding unnecessary relapse and the need for hospitalisation. This includes access to stable housing options and links with personal support services. A recent review by the NSW Ombudsman has found that around one-third of psychiatric patients living in mental health facilities did not need to be there, but could not be discharged because no suitable accommodation was available.34

It was noted during the planning process, that the lack of access to housing options such as supported accommodation is a significant factor delaying the discharge of acute patient from inpatient services in the Mid North Coast. In particular, there is a lack of supported accommodation in Port Macquarie. Many people in inpatient units are capable of living in the community with the right support. HASI packages should include a range of options including day only, short stay and group homes to provide for consumers with varying needs.

The MNCLHD will need to increase its ambulatory support to people living in supported accommodation and advocate for improved access to supported accommodation services in the Mid North Coast and seek to balance the equitable access to available accommodation on a district-wide basis.

10.3.12 Improve the Physical Health of People with Mental Illness

There is an increasing recognition that the poor physical health and early deaths of people with mental health conditions is a major health issues in Australia27. Mental illness is associated with physical health risks such as higher smoking rates, poor diet and insufficient physical activity. The three major causes of early death are suicide, cancer and cardiovascular disease.

The National Mental Health commission has recommended that all government funded mental health programs are measured on how they support better physical health and longer lives27. The Mid North Coast LHD Mental Health service should therefore review the access to general health services for consumers, provide improved physical activity programs for consumers in both inpatient and ambulatory settings and give priority to monitoring both physical and mental health needs of consumers.

10.3.13 Improve access to allied health services for Mental Health Inpatients

Mental health inpatients at the various mental health inpatient units on the Mid North Coast require improved access to allied health services such as dietetics, pharmacy and physiotherapy. Historically, designated allied health staff have not been included within the Mental Health Service staffing establishment. In order to better meet the mental and physical health needs of patients while they

34 NSW Ombudsman (2012) Denial of Rights: the need to improve accommodation and support for people with psychiatric disability



81

are admitted to the mental health inpatient units will require improved access to the centralised Allied Health Team resources.

10.3.14 Services for Aboriginal People

Up to 15 per cent of the 10 year life expectancy gap between indigenous and non-indigenous Australians has been attributed to mental health conditions35. Historically, Aboriginal people have not accessed mental health services at levels appropriate to the needs present in Aboriginal communities. There are a number of reasons for this, including a general distrust of government provided health services due to past and present discriminatory treatment and past association of health services with removal of children, and the lack of Aboriginal people working in mental health services36.

In 2012, 9.7% of active mental health community ambulatory clients identified as indigenous, emphasizing the importance of taking steps to increase the Aboriginal mental health workforce and to provide appropriate levels of cultural training for the mainstream workforce.

There is a recognition that assessment, diagnosis, treatment and care of Aboriginal clients should be conducted within an holistic and culturally sensitive and appropriate model of care. In this regard, a skilled and valued workforce is the foundation of a successful and growing Aboriginal mental health program. At present the MNCLHD Mental Health Service has an establishment of 3.45 FTE positions in its Aboriginal Emotional Wellbeing Service. There is a recognised need to enhance the size of this workforce to ensure a greater capacity to respond to the needs in Aboriginal communities in the Mid North Coast.

There is a statewide target to achieve an Aboriginal workforce commensurate with their population share (2.6%)37, and within MNCLHD, a stretch target of 5% of total positions to reflect the higher proportionate Aboriginal population in the Mid North Coast. Currently there are 207 FTE clinical staff working in inpatient and ambulatory mental health services for the MNCLHD. A target of 5% translates to around 10.3 positions, around seven positions more than the current Aboriginal workforce.

The recruitment and retention of an enhanced Aboriginal Mental Health workforce will require the implementation of specifically designed Aboriginal identified and/or targeted recruitment and retention processes including the ongoing provision of training places, skills development, access to targeted and mainstream mental health positions, peer support and mentoring. In regard to the latter, improved access to the Clinical Leader position based in Lismore would provide valuable leadership and support. In the provision of mental health services to the Aboriginal community it is important that this occurs within an environment that recognises and supports partnerships with other key service providers, including the Aboriginal Medical services on the Mid North Coast. In this respect, there is a good model of partnering at Bowraville where the CNC from Durri AMS is working closely with the local LHD and community. 35 Vos T, Barker B, Stanley L, Lopez, A. (2007) The burden of disease and injury in Aboriginal and Torres Strait Islander peoples. 36 Ministry of Health (2007) NSW Aboriginal Mental Health and Well Being Policy 2006-2010 37 Ministry of Health (2011) Aboriginal Workforce Strategic Framework Policy



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10.3.15 Increased Capacity to respond to the Needs of Refugees and Recent Immigrants

The Mid North Coast is home to a growing population of people from culturally and linguistically diverse communities including recent immigrants from countries such as the Sudan, Burma and Democratic Republic of Congo.

Members of these communities may have complex needs and culturally different beliefs relating to how they perceive and describe illness and how they access treatment and participate in recommended recovery programs.

There is a recognised need to develop culturally appropriate services to respond to their specific needs and to develop pathways to care, training for service providers and access to interpreters.

A transcultural mental health worker (0.6FTE) was based in Coffs Harbour for a period as part of the Transcultural Rural and Remote Outreach Project.38 This time-limited project has now been evaluated and there is a strong case to reinstate this position as a permanent position in Coffs Harbour to continue the development of pathways to care for these communities and to provide training for service providers in how best to respond to mental health issues in refugee and immigrant communities.

10.3.16 Health Promotion, Prevention and Early Intervention

NSW has developed a framework for promotion of mental health and well-being, prevention of mental illness and mental health problems and intervention early in the development of mental health problems. It is important that local mental health staff are familiar with this framework and play their part in developing and implementing local strategies.

There is a need for the Mid North Coast LHD to develop a greater capacity to develop strategies targeted for the local community and this could occur through developing partnerships and opportunities with academic health facilities such as the Centre for Rural and Remote Mental Health (CRRMH) and programs such as the Rural Adversity Mental Health Program (RAMHP).

There is also a need to develop partnerships between Mental Health services and primary care services including Medicare Locals in projects and programs targeting issues such as Safe Start initiatives, screening opportunities, physical health screening and improvement opportunities.

10.3.17 Research Capacity

The MNCLHD Mental Health Service does not currently have a significant research capacity, however the Service intends to build links over the next five years with an academic health facility in the development of such a capacity. This could include the development of a formal links with academic health facilities such as the Centre for Rural and Remote Mental Health (CRRMH) via an MOU which would provide opportunities for the development of conjoint appointments, co-location of research staff, capacity building opportunities for clinical staff in undertaking research, and opportunities to partner in bids for research projects.

38 Transcultural Mental Health (2010) Transcultural Rural and Remote Outreach Project



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The development of links with tertiary education institutions and academic health facilities such as CRRMH will have associated benefits such as the capacity to incorporate research and education opportunities as part of clinical job descriptions in order to increase the attractiveness of the Mid North Coast as an employer for mental health staff.



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APPENDICES



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Appendix One

Table A1 Mid North Coast Resident Demand by LGA for Inpatient Mental Health Services

Designated Wards Other Wards (non-designated) Total Mental Health separations (all wards)2010/11 LGA of Residence Separations Beddays Separations Beddays Separations Beddays Separations Beddays Separations Beddays Separations Beddays Separations Beddays Separations Beddays Separations Beddays

Bellingen 55 1050 3 328 58 1378 35 93 3 11 38 104 90 1143 6 339 96 1482Coffs Harbour 405 7434 14 1166 419 8600 201 305 5 20 206 325 606 7739 19 1186 625 8925Nambucca 97 1586 7 341 104 1927 32 190 0 0 32 190 129 1776 7 341 136 2117Coffs Harbour Network 557 10070 24 1835 581 11905 268 588 8 31 276 619 825 10658 32 1866 857 12524Kempsey 229 3527 6 443 235 3970 131 267 0 0 131 267 360 3794 6 443 366 4237Port Macquarie-Hastings 355 6405 16 2013 371 8418 290 1534 8 32 298 1566 645 7939 24 2045 669 9984Hastings Macleay Network 584 9932 22 2456 606 12388 421 1801 8 32 429 1833 1005 11733 30 2488 1035 14221MID NORTH COAST 1141 20002 46 4291 1187 24293 689 2389 16 63 705 2452 1830 22391 62 4354 1892 26745

Acute Sub/Non-Acute TotalAcute Sub/Non-Acute Total Acute Sub/Non-Acute Total




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Table A2 Mid North Coast Resident Demand for Inpatient Mental Health Services by Diagnosis Related Group

Mental Health Separations 2010/11 Mid North Coast ResidentsDRG Separations Beddays Separations Beddays Separations Beddays ALOS

B63Z Dementia and Other Chronic Disturbances of Cerebral Function 15 596 15 596 39.7B64B Delirium W/O Catastrophic CC 2 21 2 21 10.5B67A Degenerative Nervous System Disorders W Catastrophic or Severe CC 1 34 1 34 34.0B78B Intracranial Injury W/O Catastrophic or Severe CC 1 62 1 62 62.0B81B Other Disorders of the Nervous System W/O Catastrophic or Severe CC 1 1 1 1 1.0F73A Syncope and Collapse W Catastrophic or Severe CC 1 7 1 7 7.0G66Z Abdominal Pain or Mesenteric Adenitis 1 1 1 1 1.0H63A Disorders of Liver Except Malig, Cirrhosis, Alcoholic Hepatitis W Cat/Sev CC 1 1 1 1 1.0J64A Cellulitis W Catastrophic or Severe CC 1 33 1 33 33.0K62B Miscellaneous Metabolic Disorders W/O Catastrophic or Severe CC 2 3 2 3 1.5K64B Endocrine Disorders W/O Catastrophic or Severe CC 1 23 1 23 23.0M64Z Other Male Reproductive System Diagnoses 1 3 1 3 3.0O61Z Postpartum and Post Abortion W/O OR Procedure 1 1 1 1 1.0O66Z Antenatal and Other Obstetric Admission 1 1 1 1 1.0Q61B Red Blood Cell Disorders W/O Catastrophic or Severe CC 1 15 1 15 15.0U40Z Mental Health Treatment, Sameday, W ECT 72 72 72 72 1.0U60Z Mental Health Treatment, Sameday, W/O ECT 44 44 294 294 338 338 1.0U61Z Schizophrenia Disorders 277 8116 23 115 300 8231 27.4U62A Paranoia & Acute Psych Disorder W Cat/Sev CC or W Mental Health Legal Status 17 623 2 2 19 625 32.9U62B Paranoia & Acute Psych Disorder W/O Cat/Sev CC W/O Mental Health Legal Status 33 458 7 27 40 485 12.1U63Z Major Affective Disorders 208 4786 66 692 274 5478 20.0U64Z Other Affective and Somatoform Disorders 87 920 80 343 167 1263 7.6U65Z Anxiety Disorders 22 229 55 231 77 460 6.0U66Z Eating and Obsessive-Compulsive Disorders 8 148 9 259 17 407 23.9U67Z Personality Disorders and Acute Reactions 190 2011 92 404 282 2415 8.6U68Z Childhood Mental Disorders 5 44 5 13 10 57 5.7V60Z Alcohol Intoxication and Withdrawal 17 177 17 177 10.4V61Z Drug Intoxication and Withdrawal 31 419 31 419 13.5V62A Alcohol Use Disorder and Dependence 32 629 32 629 19.7V62B Alcohol Use Disorder and Dependence, Sameday 56 56 56 56 1.0V64Z Other Drug Use Disorder and Dependence 18 141 18 141 7.8X40Z Injuries, Poisoning and Toxic Effects of Drugs W Ventilator Support 1 35 1 35 35.0X60A Injuries W Catastrophic or Severe CC 2 16 2 16 8.0X60B Injuries W/O Catastrophic or Severe CC 13 67 13 67 5.2X62A Poisoning/Toxic Effects of Drugs and Other Substances W Cat or Sev CC 7 50 7 50 7.1X62B Poisoning/Toxic Effects of Drugs and Other Substances W/O Cat or Sev CC 34 304 34 304 8.9X64B Other Injury, Poisoning and Toxic Effect Diagnosis W/O Cat or Sev CC 4 37 4 37 9.3Y62A Other Burns W CC 1 4 1 4 4.0Z60A Rehabilitation W Catastrophic CC 3 235 3 235 78.3Z60B Rehabilitation W/O Catastrophic CC 37 3886 37 3886 105.0Z64A Other Factors Influencing Health Status 9 56 9 56 6.2Total Mid North Coast 1187 24293 705 2452 1892 26745 14.1

Total separations (all wards)Designated Wards All Other Wards




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Table A3a Mid North Coast Resident Demand for Inpatient Mental Health Services by Hospital (Designated Wards)

2010/11 Hospital Separations Beddays Separations Beddays Separations Beddays

Coffs Harbour 473 9373 24 2240 497 11613Port Macquarie 196 3852 196 3852Kempsey 150 2427 150 2427 Sub-total MNC 819 15652 24 2240 843 17892Private Hospitals 186 2227 186 2227Lismore 44 682 44 682Manning 25 226 25 226Bloomfield 1 23 9 1137 10 1160Queensland Hospital 7 75 1 21 8 96Tweed Heads 7 60 7 60Orange 3 18 4 147 7 165Wingham 0 0 6 691 6 691St. Vincents - Public 4 64 4 64JF - Morisset 4 511 4 511Westmead 3 9 3 9RNS - Coral Tree 3 12 3 12John Hunter 3 83 3 83Wyong 3 9 3 9Nepean 3 14 3 14Macquarie 3 90 3 90Armidale 2 2 2 2Royal Prince Alfred 2 33 2 33Manly 2 35 2 35Hornsby 2 57 2 57Tamworth 2 13 2 13Children's Hospital Westmead 2 8 2 8Maitland 2 4 2 4JF - Newcastle 2 35 2 35Concord 1 30 1 48 2 78Kenmore 0 0 1 7 1 7Goulburn 1 7 1 7Liverpool 1 2 1 2Sydney Childrens 1 2 1 2Gosford 1 8 1 8Broken Hill 1 9 1 9Dubbo 1 2 1 2Total Mid North Coast 1141 20002 46 4291 1187 24293

Designated WardsAcute Sub/Non-Acute Total




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Table A3b Mid North Coast Resident Demand for Inpatient Mental Health Services by Hospital (Non-Designated Wards)

2010/11 Hospital Separations Beddays Separations Beddays Separations Beddays

Coffs Harbour 216 283 216 283Port Macquarie 101 278 101 278Kempsey 97 129 97 129Bellinger River 12 60 12 60Wauchope 12 53 12 53Macksville 9 106 9 106Dorrigo 8 16 8 16 Sub-total MNC LHD 455 925 455 925Private Hospitals 210 1337 210 1337Tresillian (P/W) 0 0 12 47 12 47Sydney Childrens 3 9 3 9Children's Hospital Westmead 3 42 3 42Tweed Heads 3 3 3 3Karitane 0 0 2 8 2 8Tresillian, Penrith 0 0 2 8 2 8Victorian Hospital 2 2 2 2Queensland Hospital 2 2 2 2Lismore 1 1 1 1Inverell 1 1 1 1Tamworth 1 4 1 4Scone Scott Memorial 1 1 1 1Manly 1 1 1 1Shoalhaven 1 1 1 1Westmead 1 40 1 40Blacktown 1 1 1 1Auburn 1 1 1 1Casino 1 1 1 1Prince of Wales 1 17 1 17Total 689 2389 16 63 705 2452

Other Wards (non-designated)Acute Sub/Non-Acute Total


mid north coast local health district mental health...

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