NMHEC-RAP - Northern Mental Health Emergency Care - Rural Access Program

Dr. Rahul Gupta MBBS, MD, DNB, FRANZCP

Clinical Lead

NMHEC-RAP Telepsychiatry Service

NMHEC-RAP Team

Dr. Marcia Fogarty (Executive Director-MH)

Anne Unicomb (Project Manager-MOH)

Peter Kemp (Service Director)

Dr. Rahul Gupta (Clinical Lead)

Pam Davis/Sophie Phillips (Team Managers)

Kate Simpson (Clinical Coordinator)

Jay Jones (Project Coordinator)

NMHEC-RAP Clinicians

Outline

• Introduction

• Project Background

• Operating Procedures

• Facts & Figures

• Summary

• Resources

Background

• Challenges of Rural EDs• MH patients often present to the nearest ED• Few MH resources• MH Clinicians where available – cover vast distances• Many EDs have no MH cover

• Resulting in• Extending waiting times• Transfer to nearest MH facility• Limited transport options

Background

• MOH-NSW funded project

• “Living Well – A Strategic Plan” (Mental Health Commission of NSW, 2014)

• Establish new mental health resource hub• staffed - mental health professionals, • operating 24 x 7• support rural and remote EDs of northern NSW.

• NMHEC-RAP is joint initiative• Hunter New England LHD, • Mid North Coast LHD,• Northern NSW LHD.

MHA 2007 Changes -Aug 2015

• Medical officers (in absence of AMOs) can do Schedule 1 (s19A) and Form 1(s27A) via videoconference in a Gazetted MH facility.

• AMOs can undertake Form 1 assessments at a Gazetted MH facility of which they are not an employee

• Accredited Persons (APs) can do Schedule 1 (s19A) via videoconference

NMHEC-RAP Principles

• Mental Health Professionals provide MH consultations

• To regional, rural and remote EDs

• Poor access to mental health services

• Use video conference to link with EDs

• Utilize a consultation-liaison model i.e. ED retains the clinical responsibility of the patient.

NMHEC-RAP Principles

• NMHEC-RAP provides full MH access to smaller EDs

• For others, it is an enhancement of existing mental health cover to EDs• complementing existing services and extending after-hours

cover

• It is not meant to replace existing MH input to EDs

Other Telepsychiatry Services

ORANGE

WAGGA

WAGGA

GOULBURN

NEWCASTLE

NEWCASTLE

23 Current Sites

• Hunter New England - 18

• Northern NSW - 4

• Mid-North Coast - 1

Project Planning

• Site visits & Consultation – other Services, EDs.

• Development of Operational Procedures

• Training of MH Staff

• MH Act Accreditation

• Medical Credentialing

• VC hardware & installation

• Set up Hub and distant sites

NHMEC-RAP Hub Location

• Located at the grounds of James Fletcher Hospital, Newcastle

• Staff• Mental Health Professionals – multi-disciplinary

• Medical staff – Psychiatrist 0.6 FTE & Psych Reg 1.0 FTE

• Service Director, Team Manager & Clinical Coordinator

• Project Coordinator

NHMEC-RAP assessment room

Workstation on Wheels “WOW”

NMHEC-RAP

Operational model

Operating Procedures Document

Triage

• Australasian Triage Scale

Triage Code Treatment Acuity MH Descriptors

1 Immediate Definite danger. Immediate threat of violence.

2 Emergency [within 10 min] Probable danger. Restrained

3 Urgent [within 30min] Possible danger. Distressed

4 Semi-urgent [within 60min] Moderate distress

5 Non-urgent [within 120 min] No acute distress

Patient Information SheetWhat is a NMHEC_RAP assessment? A NMHEC-RAP assessment is a mental health assessment where you and the mental health professional are not in the same room as each other and use technology to complete the assessment.

Can a family member be with me during the assessment? NMHEC-RAP encourages family and/or carers to participate in the assessment, if this is your wish. You can choose any support person to be with you during the assessment.

How will I see the mental health professional if we are not in the same room? The NMHEC-RAP assessment is conducted using a portable videoconferencing machine with a camera, audio and a screen.

Can I ask questions during the consultation? You and your carer should feel free to ask questions at any time before, during and after the assessment.

Why use NMHEC-RAP? A NMHEC-RAP assessment means that you will not need to travel to another hospital to be assessed. You may, however, need to travel to another hospital if you need to be admitted.

What if I don’t want to be part of a NMHEC-RAP assessment? You may choose not to participate in a NMHEC-RAP assessment. Alternative arrangements will be discussed with you.

Consent for the assessment You will be asked for your verbal consent before the assessment starts.

What if I am uncomfortable during the NMHEC-RAP assessment? You can ask to stop the assessment at any time.

Who will be part of the consultation? You will see the mental health professional on the screen. There may also be a staff member with you in the room if you do not a have support person and it is felt that you require one. All staff involved in the assessment will introduce themselves at the beginning of the session.

Maintaining your privacy and confidentiality All NMHEC-RAP assessments are secure and subject to the same privacy requirements as face-to-face Health services. The assessment will not be recorded. The mental health professional will take notes during the assessment which will be entered into your medical record, as would normally happen if you saw a Health professional face to face.

How much will the consultation cost? This service is free for people presenting to emergency departments.

eMR - CHIME (HNE)

eMR – CERNER (NNSW & MNC)

Benefits - Recap

• Patients access MH assessment and care closer to home

• Reduce need to transport to MH facility for mental health assessment.

• EDs - reduce waiting times for mental health assessments

• Comprehensive, contemporaneous, standardised electronic clinical documentation in CHIME

Inverell

MH Room

Challenges

Some Challenges

• Appropriate referral: ED – MH Interface!!• Patient selection

• Consent

• Variations in processes across sites/LHDs.

• Different eMRs – CHIME & CERNER

• Contact with Staff specialists – various processes for LHDs, intra-LHD.

Some Challenges

• Role diffusion: EDs –> NMHEC-RAP <– MH Services

• Workflow – Unpredictability of NMHEC-RAPs referrals

• Diversion from non-NMHEC-RAP EDs

Some Facts & Figures

Assessments till date

0

100

200

300

400

500

600

700

800

900

2016 (5m) 2017 2018 (9m)

Assessments Done = 1495

•Activity FY 2017-18

NMHEC-RAP Assessments Per Month

Total Assessments = 969

0

20

40

60

80

100

120

Referrals by Month

Number of Referrals

Assessments Per LHD

HNE 53%NNSW 47%

MNC

Chart Title

HNELHD

NNSWLHD

MHCLHD

Age Ranges of Referrals

C&A 20%

Adult 77%

Older 3%

Age Range

0 to 18

18 to 65

65 plus

Scheduled Prior to NMHEC-RAP Referral

95% of referred patients are

voluntary

95% Voluntary

5% Scheduled

Scheduled Patients Prior to NMHEC-RAP

No

Yes

Times of the Day of Referral Requests

There is little variation in

activity between morning &

afternoon shifts.

07:00-15:00 15:01-23:00 23:01-07:00

Times of Day

ED referral by Time of Day

Referrals at hourly

intervals.

Peak time 11am- 6pm.

0

10

20

30

40

50

60

70

80

90

Time of NMHEC-RAP Requests

Time From Referral to Commencement of Assessment

38% within 30 minutes

66% within one hour

0 100 200 300 400 500 600 700 800

>0-1 hours

>1-2 hours

>2-3 hours

>3-4 hours

>4-5hours

>5-6 hours

>6-7 hours

>7-8 hours

>8-9 hours

>9-10 hours

>10-11 hours

>11-12 hours

>12-13 hours

>13-14 hours

>14-15 hours

2/3rd Assessments commenced in 60min

Completion Rate

Assessment Recommendations

26.4% were referred to

inpatient facilities

0

50

100

150

200

250

300

350

400

450

500

Inpatient CMHT/ACS GP CAMHs Other OtherPrimaryHealth

Blank

Referral Recommendations

• References

• https://www.ranzcp.org/Publications/Telehealth-in-psychiatry.aspx

• Saurman, E., Kirby, S. & Lyle, D. (2015). No longer flyingblind: how access has changed emergency mental healthcare in rural and remote emergency departments, aqualitative study. BMC Health Services Research. Vol15:156.

• Guidelines for the use of Telehealth for Clinical and Non Clinical Settings in NSW. https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0010/258706/ACI-telehealth-guidelines.pdf

•END