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Type secondary title for document if required

Statewide Borderline

Personality Disorder

Collaborative Operational Guidelines

June 2019

Country Health SA LHN

Mental Health Services

Adult Integrated Community Mental Health Teams

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Version Control

Version Release Date

Change Author Approved

V1 6/6/19 First draft for consultation Borderline Personality Disorder Collaborative

Disclaimer No responsibility is accepted by Country Health SA Local Health Network for any errors

or omissions contained within this publication. The information contained within the

publication is for general use only. No liability will be accepted for any loss or damage

arising from reliance upon any information in this publication.

TRADITIONAL LANDS OF THE KAURNA PEOPLE We acknowledge the Borderline Personality Disorder Collaborative (BPD Co) hub is

located on the traditional lands of the Kaurna people and pay respect to their spiritual

relationship with this country. BPD Co will provide care for Aboriginal people from other

communities across Australia.

The term Aboriginal is used respectfully throughout this document to refer both to

Aboriginal and Torres Strait Islander people, although it is acknowledged that this

encompasses a large number of diverse communities.

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Contents 1. Purpose ............................................................................................................................................... 4

2. Background ......................................................................................................................................... 4

2.1. Overview of the BPD Co Model of Care ...................................................................................... 4

3. The Statewide Service ......................................................................................................................... 6

3.1. Overview ..................................................................................................................................... 6

3.2. Staffing ........................................................................................................................................ 6

3.3. Governance of the Statewide BPD Service ................................................................................. 7

3.4. Team Structure and Org Chart .................................................................................................... 7

3.5. Hub and Spoke Model Outline .................................................................................................... 9

3.6. Hub and Spoke Service Governance Principles ......................................................................... 10

3.7. Roles and Responsibilities within the hub and spoke service................................................... 11

3.7.1. Hub Clinicians ......................................................................................................................... 11

3.7.2. Lived Experience Project Officers .......................................................................................... 12

3.7.3. Training Coordinator .............................................................................................................. 13

3.7.4. Research Project Lead and Officer ......................................................................................... 13

3.7.5. Networked Clinicians ............................................................................................................. 13

3.8. Client Information Systems ....................................................................................................... 13

3.9. The Stepped Model of Care ...................................................................................................... 13

3.10. Other services offered across the Model of Care ..................................................................... 22

3.11. Services provided outside SA Health ........................................................................................ 22

3.12. Workforce Development and Training ..................................................................................... 23

3.13. Research and Quality Assurance ............................................................................................... 24

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1. PURPOSE

The Borderline Personality Disorder Collaborative (BPD Co) Operational Guidelines

underpin the BPD Co Model of Care and are to be read in conjunction with the BPD Co

Model of Care Document. The Operational Guidelines provide an overarching

framework for operationalisation of the elements of the BPD Co Model of Care and

detail the parameters within which the statewide service will operate. This document is

intended as a guide and will evolve and be refined over time in the context of review,

evaluation and a commitment to continuous improvement.

2. BACKGROUND

2.1. Overview of the BPD Co Model of Care

The statewide BPD Co has been developed by Country Health SA Local Health Network

(CHSALHN) and will be administered by Barossa Hills Fleurieu LHN as of 1 July 2019.

The BPD Co initiative evolved in response to the demonstrated need for enhanced,

evidence-based BPD service development in South Australia. The Model of Care was

developed through a process of extensive consultation and collaboration with multiple

stakeholders, including consumers and carers with lived experience of BPD, across

South Australia and interstate. The processes of designing, operationalising and

implementing services within the Model of Care will continue to incorporate active

partnership and consultation with people with lived experience, their carers and

clinicians, and other stakeholders including government and non-government agencies.

The BPD Co outlines a hub and spoke service model to facilitate increased capacity for

BPD-specific service delivery within LHNs and the operation of an integrated BPD

service across the State, that incorporates interface with private practitioners and

community-based services, as well as LHN-based services.

The hub (or central office) is located on the fringe of the city of Adelaide, and the spokes

are the public health BPD services within Local Health Networks.

The BPD Co, across hub and spokes, will incorporate four elements:

˃ clinical services for people with severe and complex BPD

˃ advocacy for enhanced access to treatment for people living with BPD to mainstream acute and specialist outpatient and therapeutic services, including group programs across South Australia

˃ an Early Years and New Parents Program

˃ development of system capacity to support and treat young people at-risk of developing BPD, or with early signs of BPD

The outcomes to be achieved over time include:

˃ improved access to appropriate early intervention services

˃ improved access to appropriate evidence-based services

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˃ improved access to recovery-focussed services

˃ reduction in the level of suicide and deliberate self-harm by those who suffer from BPD

˃ decreased presentations to hospitals, including emergency departments, by consumers with a diagnosis of BPD

˃ decreased experience of stigma and discrimination faced by those with a diagnosis of BPD.

2.1.1. Key Principles of the Model of Care

˃ We believe that people with BPD can and do recover to engage in meaningful lives.

˃ We will promote person-centred care, validating trauma if disclosed, and tailoring the therapeutic approach to individual needs.

˃ We will work in partnership with families and carers, supporting them in their caring role and providing them with information about BPD.

˃ We will promote evidence-based care in local communities.

˃ We will partner with other providers to ensure equitable, accessible and timely service.

˃ We will match our BPD care to windows of opportunity across the life span.

˃ We will sustain clinicians through ongoing learning, support and supervision.

˃ We will provide a safe and responsive service for Aboriginal people, culturally and linguistically diverse groups and LGBTQI clients.

˃ We will encourage innovative, flexible approaches responsive to local community needs across the State.

˃ We will take a long-term view together with community to build a sustainable BPD service.

2.1.2. The Stepped Model of Care

The NHMRC (2012) Clinical Practice Guideline for the Management of BPD (2012)

describe Stepped Care as “beginning with the least intensive treatment that is likely to

be effective, then monitoring response to increase or reduce the intensity of the

intervention according to the person’s needs”.

The steps of care outlined in the BPD Co Model of Care are:

˃ Assessment and Brief Intervention Clinics (ABiCs)

˃ Short-term Evidence-Based Group Therapy

˃ Severe and Complex Shared Care.

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2.1.3. Implementation

Given the complexity and breadth of the Model of Care across multiple practitioners,

organisations, and systems, across the state, implementation will occur in a staged

manner. This will ensure opportunity to build capacity, facilitate culture change and

embed evaluation and review mechanisms to facilitate the sustainability of the Model of

Care over time.

It is anticipated that a formal evaluation of both the BPD Co Model of Care and

Operational Guidelines will be implemented mid-2022. However there will be a

continuous focus on monitoring, evaluation and refinement of the services within the

Model of Care from their inception.

3. THE STATEWIDE SERVICE

3.1. Overview

The BPD Co will work in close partnership with each of the LHNs to consolidate and

augment capacity and to improve access to BPD-specific services and treatment

options for consumers close to where they live. Services will be provided by LHNs, by

BPD Co, and by Non-Government Organisations (NGOs).

3.2. Staffing

The centre will be staffed by a multidisciplinary team to facilitate a comprehensive,

holistic approach to service delivery and care. The workforce will comprise a range of

clinical and non-clinical roles, facilitated by staff from a range of professional

backgrounds, including:

˃ Medical/Psychiatry

˃ Nursing

˃ Social Work

˃ Psychology

˃ Occupational Therapy

˃ Training

˃ Research

˃ Aboriginal Mental Health Worker/Social Emotional Wellbeing Worker

˃ Lived Experience Project Officer – Consumer

˃ Lived Experience Project Officer – Carer

˃ Administration Staff

Clinical staff will have strong skills, knowledge and experience in providing mental

health care for people with a diagnosis of BPD, as well as discipline-specific skills,

knowledge and an understanding of the Mental Health Act 2009. Additionally, they will

meet the National Practice Standards for the Mental Health Workforce 2013 and

consistent with the expectations outlined in the Country Health Mental Health Services

(MHS) Community Mental Health Model of Care and Operational Pathways (June

2017), have a core set of skills in the following areas:

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˃ Therapeutic engagement through skillful communication

˃ Mental state examination, risk assessment and management

˃ De-escalation of aggressive incidents

˃ Care planning

˃ Family and carer involvement

˃ Community engagement and primary health care principles

˃ Early intervention and preventative strategies

3.3. Governance of the Statewide BPD Service

From 1st July 2019, the statewide BPD Co will be situated under the operational

governance of the Barossa Hills Fleurieu (BHF) LHN. The 10 LHNs across the state will

be represented on a Statewide Advisory Committee to facilitate ongoing opportunity to

contribute to the strategic directions of BPD Co and to influence the evolution and

refinement of services within the Model of Care over time.

3.4. Team Structure and Org Chart

As of the 1st July 2019, the BPD Co will be accountable to the Barossa Hills Fleurieu

Clinical Director, Mental Health Services. The BPD Co Clinical Lead and Advanced

Clinician/Coordinator will both report to the BHF Clinical Director within a co-leadership

model. The Clinical Lead will hold clinical accountability for the service and the

Advanced Clinician/Coordinator will hold operational accountability.

Clinicians will be professionally accountable to the relevant CHSA Advanced Clinical

Lead.

Structures will be developed to facilitate access to appropriate support, supervision and

professional development opportunities for Lived Experience Project Officers.

Staff in the Administrative Services stream will be provided with discipline-specific

professional support to aid maintenance of professional standards and ensure

development of skills and knowledge.

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Figure 2. Team Structure of the BPD Co

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Figure 3. Professional Reporting Structure

3.5. Hub and Spoke Model Outline

The BPD Co will operate as a hub and spoke model, where the BPD Co will be the hub

and the LHNs, inclusive of the three metropolitan LHNs, WCHN LHN and the six CHSA

LHNs (from 1st July 2019), will be the spokes.

Hub clinicians will be employed and managed by the BPD Co, however will be

connected with a primary LHN in which they will spend the majority of their time. Hub

clinicians will provide care in accordance with the BPD Co Model of Care, from both the

hub and the LHN to which they are primarily allocated. They may also provide care from

other LHNs if clinically indicated. It is anticipated that hub clinicians will spend

approximately 1.5 days per week operating from the hub, with the remainder of their

time situated within the LHN to which they are allocated. This will vary however, in

accordance with the FTE of the clinician, the stage of implementation, BPD Co priorities,

resource availability and LHN needs and priorities. The division of time across the Hub

and LHN will be individually negotiated upon establishment of each of the roles within

Clinical Lead

Psychology

Nursing

Medical Staff

Social Work

Occupational

Therapy

Director of

Nursing

Advanced

Clinical Lead

Psychology

Advanced

Clinical Lead

Social Work

Advanced

Clinical Lead

Occupational

Therapy

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LHNs and will be regularly reviewed to facilitate responsiveness to the changing needs

and priorities of services and the system over time.

Allocation and connection of clinicians to particular LHNs will be determined on the

basis of skillset, stage of implementation, BPD Co priorities and LHN needs and

priorities.

Hub clinicians will work in close partnership with networked clinicians within their

primary LHN to support implementation of the Model of Care.

Hub clinicians primarily connected with country LHNs may be located within a regional

location, or operate from a metro base. Irrespective of their primary location, given the

breadth of geographic area covered by CHSA, use of technology will be an important

component of clinical service delivery in regional locations. Consistent with the Country

Health MHS Community Mental Health Model of Care and Operational Pathways (June

2017), the BPD Co will:

˃ Use DTN technology where available to offer access to specialist assessment and intervention in order to supplement what can be offered locally, and to engage consumer’s networks and supports in the therapeutic process;

˃ Govern all use of technology through privacy and safety principles;

˃ Ensure that appropriate training and evaluation of the use of e-mental health services in daily practice is provided to relevant clinical staff.

3.6. Hub and Spoke Service Governance Principles

Initial hub and spoke governance principles to inform clinical service development and guide

governance of the state-wide BPD service were determined by clinical and executive leaders

across LHNs in the planning and development phase of the BPD Co.

The principles are as follows:

˃ The LHNs will support the Model of Care proposed by the BPD Co and will commit to progressing it.

˃ An advisory Committee will be formed with representation from the LHNs and BPD Co and will provide overarching governance.

˃ Key performance indicators will be discussed, agreed upon and established by the BPD Co and LHNs.

˃ Agreed resolution processes will be developed for managing differences between the hub and the spokes

˃ Clinical governance responsibility for consumers’ care remains within the LHNs.

˃ The BPD Co clinical staff recruitment process will consider specific and unique LHN needs and requirements wherever possible.

˃ Clarification of the roles of hub clinicians will be determined in consultation between the BPD Co and the LHNs

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˃ Each LHN will identify local networked clinicians and case load volume and will seek to match internally the level of clinical resource provided by the BPD Co.

˃ Most referrals to the BPD Co will come via the LHNs.

˃ LHNs will develop triage pathways for BPD clients and their carers.

The hub and spoke governance principles will be augmented by the development of formal Local Service Agreements (LSAs), which will detail the principles by which the BPD Co and LHNs will work together; expectations regarding communication, information and data sharing; processes for negotiating differences of opinion and clarification regarding the delineation of responsibilities.

3.7. Roles and Responsibilities within the hub and spoke service

3.7.1. Hub Clinicians

The Hub Clinicians will undertake a range of functions within their role, which may

include:

Evidence-Based Care:

˃ Initially undertaking the role of clinic coordinator for the ABICs, prior to the role being transferred to LHN clinicians;

˃ Undertaking a group facilitator role in collaboration with LHN/Networked Clinicians;

˃ Undertaking case reviews including the development and management of care plans and crisis plans;

˃ Provision of individual therapy for consumers with Severe and Complex BPD, either in the hub or LHN;

˃ Advocacy for stepped care and facilitating different steps of the Statewide Model of Care;

˃ Liaison with Private Practitioners, GPs and NGOs.

Capacity-building and Training:

˃ Capacity-building, supervision, coaching and consultation to LHN clinicians (including networked clinicians), focused on core competencies;

˃ Participation in the development and delivery of training in the LHNs and other locations in conjunction with the Training Coordinator. Research and Evaluation

˃ Active participation in routine-outcome monitoring and collection of data for quality assurance processes and targeted service evaluations;

˃ Participation in research projects supported by the Research Project Officer.

Key Contact Role

˃ Hub clinicians will be rostered to provide a key contact role (approximately half a day per week) which will involve being the primary contact point for queries to the BPD Co Hub and provision of resources and information about the Model of Care. The role may also include consultation regarding pathways to access care and facilitation of referrals to the most appropriate step in the model of care via the relevant LHN (noting that in the first stages of implementation not all proposed steps of the BPD Co model of care will be available in all areas).

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˃ Country-based clinicians or those undertaking travel/outreach to support service delivery in regional areas may have limited capacity to undertake this function due to their reduced time physically in the hub.

The balance of emphasis across the range of core functions of the hub clinician will be

determined in accordance with the implementation stage, BPD Co priorities, resource

availability and LHN needs and priorities, therefore will evolve and adapt over time. The

hub clinician will work autonomously, however will be supported to manage competing

priorities within their workload through their operational and clinical reporting lines to the

hub. To facilitate this, hub clinicians will have regular access to:

˃ Operational/Clinical Supervision with the hub Advanced Clinician/Coordinator

˃ Professional Supervision with the relevant Country health Advanced Clinical Lead (Country Health LHN)

˃ Therapy-specific supervision/support as required by the different modalities (for example, DBT Consult).

In instances where there are conflicting priorities and demands, the hub clinician will be

encouraged to address this directly with the LHN in the first instance with reference to

the relevant LSA. Where this is unable to be resolved, the Hub clinician will escalate

through the Advanced Clinician/Coordinator, Clinical Lead and/or Country Health

Advanced Clinical Lead as required.

3.7.2. Lived Experience Project Officers

The Lived Experience Project Officers will identify, implement and maintain mechanisms

for purposeful and meaningful consumer, carer and community participation and

engagement. This will include:

˃ developing and maintaining consumer/carer feedback including complaints mechanisms

˃ developing and leading consumer/carer participation mechanisms

˃ contributing to and supporting training,

˃ consolidation of resources,

˃ the development of partnerships and collaborations with other services

˃ the provision of psychoeducation to consumers and carers, including implementation of evidence-based group psychoeducation programs

The Lived Experience Project Officers will predominantly be situated within the hub,

although elements of their role (such as training and teaching) will operate from LHNs,

NGOs and other locations as required. Where they provide direct support to consumers

and carers, this will be documented in the relevant client information system under the

appropriate activity code (for example, support, therapy, counselling).

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3.7.3. Training Coordinator

The BPD Co Training Coordinator will be situated at the hub and will develop,

implement, monitor and maintain a framework to support a sustainable approach to

workforce development and training.

3.7.4. Research Project Lead and Officer

The Research Lead and Project Officer will develop, implement and monitor an

overarching BPD Co research program.

3.7.5. Networked Clinicians

Networked Clinicians remain under the Operational and Clinical Governance of the LHN

in which they are operating.

3.8. Client Information Systems

There are currently two electronic client information systems operating within community

based mental health services across South Australia: the Community Based Information

System (CBIS) in metropolitan adult and child/adolescent services; and the

Consolidated Country Client Management Engine (CCCME) in country services. As a

statewide service, the BPD Co will be required to operate across both systems,

depending on the location of service delivery:

Hub clinicians operating within LHNs will enter clinical information and data into the local

system of the LHN in which the clinical service is being provided.

Services provided within the hub will be recorded and documented on CBIS.

Where care is shared across BPD Co another LHN, clinical information will be entered

into the local system of the service that holds the clinical governance responsibility for

the consumer’s care.

Consultation is currently occurring with representatives from CBIS and CCCME to

develop signifiers/codes across the BPD Co Model of Care to enable specification of

“service required” for referral management purposes. This will facilitate capacity to

clearly direct and monitor referrals appropriately. Additionally, options for best

representing and capturing activity related to the BPD Co steps of care are being

explored.

3.9. The Stepped Model of Care

3.9.1. The Assessment and Brief Intervention Clinic (ABiC)

Assessment and Brief Intervention Clinics (ABiC) will be modelled on the Gold Card

approach developed in NSW by The Project Air Strategy for Personality Disorders:

https://projectairstrategy.org/whoweare/index.html.

The Clinics will be initially piloted and evaluated in some LHN locations, with a view to

then implementing across all LHNs if found to be effective in the South Australian

context.

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The guidelines outlined below are intended as a broad guide and it is anticipated that

specific aspects of the ABiC (including mode of consumer contact and options for

inreach to Acute Units and Emergency Departments) will evolve within local parameters

as part of specific collaborative implementation processes.

3.9.1.1. Overview

In accordance with the model developed by Project Air, the Assessment and Brief

Intervention Clinic (ABiC) is a brief intervention service designed to provide a timely

response to people who have recently experienced a mental health crisis including self-

harm and/or suicidal thoughts or behaviours. The clinic offers three sessions focused

on identifying psychological and psychosocial factors that have contributed to the crisis

and introduces practical therapeutic techniques and strategies to support crisis

management. An additional session for carers and family members is included as a

component of the intervention.

ABiCs will be situated within LHNs, or with NGO partners.

3.9.1.2. Hours of Operation

ABiCs will operate during the usual business hours of the service in which they are

situated (usually Monday to Friday, 0900-1700) and will aim to offer an appointment

within 1-3 working days of receipt of referral.

3.9.1.3. Entry

Referrals to ABiCs will be accepted from multiple sources, including:

˃ Mental Health Triage (MHT) and the Emergency Triage and Liaison Service (ETLS);

˃ Hospital Emergency Departments (EDs):

˃ Inpatient units;

˃ Non-Government Organisations (NGOs);

˃ General practitioners and medical officers;

˃ Private practitioners:

˃ Self-referrals and referrals from carers/family members.

3.9.1.4. Eligibility Criteria

˃ Age range is as determined by the service in which the clinic is situated:

o Child and Adolescent Mental Health Services: 12 to 18 years

o Youth Mental Health Services: 16 to 24 years

o Adult Mental Health Services: aged 18 years and upwards.

˃ Presence of one or more of the below criteria:

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o Suicidal thoughts or plans and/or recent episodes of self-harm or suicide attempts

o Fluctuating intense emotions and high levels of distress

o Problems with identity and sense of self

o Impulsive, self-destructive behaviour

o Persistent instability in relationships

o A diagnosis of Borderline Personality Disorder or Borderline Personality Disorder traits

3.9.1.5. Exclusion Criteria

˃ High level risk requires urgent assessment and follow up. Presentations and referrals requiring urgent follow up will be directed to appropriate acute and emergency services.

˃ Acute Psychosis or Affective Disorder (such as Major Depressive Disorder, Bipolar Disorder).

˃ Alcohol and/or drug intoxication appear to be the primary presenting problem.

˃ Current engagement with ongoing structured therapy interventions.

3.9.1.6. Referral Process

Referrals to ABiCs will be directed to the relevant intake point for the specific service or

team in which the ABiC is located.

Internal referrals will be via the relevant computer-based information system (ie CBIS or

CCCME) and in accordance with the SA Health Clinical Handover Policy and the

Country Health Clinical Handover Procedure, will be in ISBAR format;

˃ External referrals may be via telephone, fax, email or written documentation. Information will be entered into the computer-based information system at the point of intake.

˃ Referrals will specifically outline a request for ABiC (utilising the appropriate code to outline the “required service” in the referral management system);

˃ Referrals will outline how the consumer’s presenting difficulties meet ABiC eligibility criteria;

˃ Referrals will include sufficient evidence of assessment of current risk to determine that immediate/urgent follow up is not required.

From the initial intake point, referrals will be directed to the ABiC Coordinator. Hub

clinicians will initially function as clinic coordinators; however this role will later be

transferred to LHN clinicians.

Once a referral is received, the ABiC Coordinator will review the available information to

determine if the referral is appropriate on the basis of eligibility and exclusion criteria.

If the referral is assessed as not appropriate, the ABiC Coordinator liaise with the

referrer to redirect to a more appropriate pathway.

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If the referral is assessed as appropriate and accepted into the Clinic, the ABiC

Coordinator will allocate to an ABiC clinician.

The allocated ABiC Clinician will then contact the consumer to schedule an initial

appointment within 1-3 business days of the original referral and inform the referrer

accordingly.

If the consumer is not contactable within 3 days, the ABiC Clinician will liaise with the

referrer to determine the most appropriate pathway for follow up.

3.9.1.7. DNA

If a consumer does not attend a scheduled ABiC appointment without having contacted

to cancel or reschedule, the allocated ABiC clinician will follow up by telephone on the

same day.

If contact is made with the consumer:

˃ The ABiC clinician will clarify the reasons for non-attendance and assess any changes to risk.

˃ If there is an indication of increased risk requiring urgent follow up, the ABiC clinician will refer to relevant crisis or emergency services.

˃ If urgent follow up is not clinically indicated, and the consumer is willing, the ABiC clinician will offer another appointment.

˃ If urgent follow up is not clinically indicated and the consumer declines further appointments, the ABiC clinician will provide feedback to the referrer with a view to closing the episode of care.

If contact is unable to be made with the consumer:

˃ Where possible the ABiC clinician will leave a message for the consumer requesting contact and reminding them of relevant crisis contacts as required.

˃ If the consumer has not contacted the service within 3 business days, the ABiC Coordinator will liaise with the referrer to determine the most appropriate pathway for follow up.

˃ If the ABiC Clinician is unable to make contact with the referrer, they will contact identified significant others, where known.

3.9.1.8. Multidisciplinary Clinical Reviews

The allocated ABiC clinician will coordinate a multidisciplinary Clinical Review or Clinical

Huddle at the following points of care

˃ The point of initial receipt of referral in cases where there is evidence of exclusion criteria and it is determined that an alternative care or treatment option may be more appropriate;

˃ Where the consumer declines the service or disengages from the service;

˃ The point of transfer of care/episode closure.

Where there is indication of increased risk to the consumer and an urgent response is

required, the ABiC clinician will follow the escalation of care guidelines and processes of

the service in which the ABiC is situated.

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3.9.1.9. Discharge Process

At the conclusion of engagement with the ABiC, the ABiC clinician will collaborate with

the consumer and, where possible and with consent, the consumer’s family members

and/or carers, to consider further treatment and support options. These may include:

˃ Provision of resources and information;

˃ Formal referral to specific, specialist services;

˃ Step up to Stage 2 or 3 of the Model of Care

˃ Transfer of care to the consumer’s General Practitioner

The preferred and most clinically appropriate option will then be discussed and ratified in

a multidisciplinary Clinical Review.

3.9.1.10. Key Performance Indicators

The ABiC clinician is responsible for:

˃ Development of a care plan in collaboration with the consumer (and carer(s) if appropriate);

˃ Completion of the NOCC suite, formal Risk Assessment and Mental State Examination as per service requirements.

˃ Any other KPI that may assist in enhancing operational and clinical outcomes or to meet service level agreements.

3.9.2. Short Term Evidence-Based Group Therapy (ie 12 week Program)

3.9.2.1. Overview

For those consumers who seek further therapy, short term group-based therapy will be

available. As there is not currently an established evidence-based program that readily

fits within the model of care, a key priority will be to develop an evidence-informed

program and evaluate its effectiveness. The intention is to pilot this within the hub, with

a view to then implementing across LHNs.

Development of the short-term program will incorporate guidelines regarding access,

eligibility, referral processes, documentation, clinical review and KPI management. It is

likely that the short-term program will initially be piloted during usual business hours,

however it is anticipated that in the future some after-hours groups may be offered

through the BPD Co hub.

3.9.3. Severe and complex shared care

3.9.3.1. Overview

The BPD Co will offer a shared care model for LHNs working with people with the most

complex and severe presentations of BPD.

3.9.3.2. Hours of Operation

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The hub and hub clinicians will operate during usual business hours (Monday to Friday,

0900-1700).

3.9.3.3. Entry

Referrals for shared care will be considered where local therapeutic options have been

exhausted, for:

˃ People with BPD who present in recurrent crisis

˃ People with BPD who experience high level complexities or comorbidities

˃ People with BPD who experience persistent difficulty in engaging with the system of care

˃ Carer referrals where there is a high level of concern for the consumer

˃ Service provider referrals where there is a high level of concern regarding the consumer with BPD.

3.9.3.4. Referral Process

Prior to formal referral, initial consultation will occur with the local hub clinician to

consider appropriateness for shared care, noting that the option of shared care will have

been discussed with the consumer and/or carer(s) prior to consultation and they are

agreeable to this option being explored.

Consultation will be based on consideration of:

˃ A comprehensive overview and summary of the history of the consumer’s engagement with services,

˃ Copies of previous assessments, including formal psychiatric reports, forensic reports, OT assessments and psychological reports as available,

˃ A current risk assessment and NOCC,

˃ Existing care plans and/or management plans,

˃ A summary of other services providing care.

If shared care is a recommended option following initial consultation, this will be

formalised via a referral in ISBAR format to the BPD Co by the LHN clinician.

The hub clinician will then undertake a BPD Co standardised assessment, including

wherever possible, separate face-to-face interviews with the consumer and carer(s).

The hub clinician will present their assessment at a BPD Co multidisciplinary clinical

review for consideration of the following care options:

˃ Treatment as usual (no formal ongoing BPD Co input).

˃ Referral to another, more appropriate agency (to be completed by the LHN).

˃ Management plan/crisis plan development or review.

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˃ Advocacy to navigate multiple service systems for care/management plan, including in some instances, provision of education/support to adjunctive service providers.

˃ Supervision, coaching and support of LHN clinicians.

˃ Advocacy for brief goal-focused hospital admission in the LHN, for the purposes of brief respite and/or for treatment of acute comorbid illness.

˃ Time-limited specialised evidence-based group program, conducted by BPD-trained therapists. This may involve collaboration and consultancy to support linking to an established BPD-program in either the public or private sector.

˃ Time-limited specialised evidence-based individual therapy, conducted by a hub clinician. Of note, as this is a statewide option, resources will be limited in the initial phases of implementation while capacity and diversity of skillset are augmented and developed through a structured workforce development approach (see workforce development/training section).

The consumer (and carer(s) if appropriate) and LHN will be advised of the outcome of

the assessment and of the associated recommendations.

A case conference will be convened, which should include the consumer (and carer(s) if

appropriate) where possible, as well as the care team and other services, agencies and

individuals as appropriate and agreed by the consumer. This will include delineation of

the roles and responsibilities of the various services and agencies, as well as

clarification of pathways for escalation of care and mobilisation of additional supports as

required.

3.9.3.5. Location of care delivery

Where a shared care arrangement is established and the BPD Co will be providing

ongoing input, the location of care delivery by the hub clinician will generally be within

the LHN (to facilitate ease of access for consumers and carers), however there is scope

to consider alternative venues, including the hub, if required.

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Figure 3 Severe and Complex Shared Care Referral Pathway

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3.9.3.6. Multidisciplinary Clinical Reviews

Following initial assessment and clinical review, further multidisciplinary clinical reviews

will occur at the following points of care:

˃ When requested by the consumer &/or carer(s).

˃ When there is a change in the consumer’s presentation and/or the intensity of service clinically indicated.

˃ Every 3 months, in accordance with National Standards for Mental Health Services.

˃ When the consumer declines the service or disengages from the service.

˃ The point of transfer of care/completion of episode of shared care.

When there is indication of increased risk to the consumer and an urgent response is

required, the clinician will follow the escalation of care guidelines and processes of the

service that holds clinical governance responsibility for the consumer’s care.

3.9.3.7. Discharge Process

Transfer of Care/closure of the BPD Co episode of care will be considered when:

˃ The consumer indicates they no longer require or are no longer willing to engage with the BPD Co service;

˃ An alternative, more appropriate specialist service is available;

˃ The goals of engagement and treatment have been met.

The plan to close the BPD Co episode of care will be discussed and ratified in a

multidisciplinary Clinical Review.

3.9.3.8. Documentation and Recording

Formal referral to the BPD Co for shared care will occur via the computer-based

information system used by the LHN initiating the request.

˃ Within CCCME (for CHSA LHNs), this will occur via a referral management episode.

˃ Within CBIS (for metro-based LHNs), this will occur via the referral management screen.

When a referral is accepted for assessment by BPD Co, subsequent documentation and

clinical records will be entered under the BPD Co Team/Agency code into the existing

episode of care open to the primary care team.

Within CBIS, the dates of the episode of shared care will be recorded in the grid in the

CBIS episode grid.

3.9.3.9. Key Performance Indicators

Timely completion of NOCCs, care plans, clinical reviews and risk assessments will

predominantly remain the responsibility of the care coordinator within the LHN holding

clinical governance accountability for the consumer. This may vary at times however,

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depending on the nature of the shared care arrangement and the specific delineation of

responsibilities across clinicians and care providers.

3.10. Other services offered across the Model of Care

It is intended that evidence-based psychoeducation and support will be provided at the

BPD Co hub or other accessible locations for those in relationship with someone with

BPD, even if the person with BPD is not themselves engaged with services. Lived

Experience Project Officers will be involved in the development and establishment of

evidence-based and evidence-informed psychoeducation groups, as well as developing

and maintaining consumer and carer engagement mechanisms for the BPD Co that

support and promote consumer and carer involvement at all levels of the service.

3.10.1. Re-entry

There are no barriers to re-entry to any of the steps of the BPD Co Model of Care if

eligibility criteria are met and no exclusion criteria are evident.

3.10.2. Access to Programs already established in LHNs

The BPD Co is committed to ongoing consultation, collaboration and partnership with

established BPD Programs and service options and to ensuring complementary

pathways to care that augment choice and positive outcomes for consumers and carers.

Where there are existing programs within LHNs, access will continue to be on the basis

of established parameters as determined by local clinicians. Consumers may be

referred either directly to these programs or as a component of their progress through

the Stepped Model of Care (ie as a component of Step 3).

3.10.3. Special Populations and BPD

The proposed pathways and steps of care of the BPD Co Model of Care are intended to

be inclusive of special populations with BPD, including those in regional areas,

Aboriginal communities, new parents (and early years), youth, and those in the criminal

justice system. As services within the model of care are implemented and established,

partnerships will be developed and consolidated with services and organisations already

working with and committed to supporting these populations. This will inform

appropriate modification and refinement of pathways and services to increase

accessibility and reduce barriers to effective service delivery with these populations.

3.11. Services provided outside SA Health

The BPD Co will consult and collaborate with organisations and clinicians outside SA

Health who provide services to people with BPD. This includes a range of private

practitioners, General Practitioners, NGOs and PHNs. These services and practitioners

will have telephone and email access to a key contact worker at the BPD Co hub during

business hours who can provide information regarding pathways to care and

direction/facilitation of appropriate referrals to the relevant step in the model of care via

the relevant LHN. It is important to note that the function of this support is to provide

information and resources. It is not intended as a crisis support option and does not

replace the need to engage with emergency services where clinically indicated.

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The option of student training and placement opportunities will be explored to facilitate

capacity to augment service delivery across each of the steps of the Model of care

centrally from the hub.

3.12. Workforce Development and Training

The Workforce development training program is key to the implementation of the hub

and spoke service model, supporting capacity building of clinicians and services utilising

a core competency framework

Through the delivery of integrated multi-level evidence-based training, we will aim to

reduce stigma associated with BPD, create a positive culture, and promote equity and

consumer participation across the system.

The training coordinator will develop the BPD Co state-wide training plan and organise

the training program to support the pilot and staged roll out of an evidence-based

stepped care model over time. Staff training needs across the mental health, health and

stakeholder sectors will be analysed to ensure the training plan and packages are

developed to meet the clinician and stakeholder needs.

Consumers and carers will participate in the development of BPD training programs,

both in terms of content development as well as the delivery of training.

The training program will be facilitated through the provision of direct training, the

brokerage of appropriate trainers or training organisations via a preferred provider

panel, as well as development of local resources via ‘train the trainer’ options to facilitate

local clinician and supervisor upskilling and education.

Consistent with the hub and spoke model, the training plan will outline a 2-tiered

approach:

3.12.1. Tier 1: Training provided to Hub staff:

All BPD Co staff will be provided with orientation appropriate to their designated role.

This will include locality specific orientation for clinicians located in the LHNs.

An ongoing programme of training will be provided for BPD Co hub staff to support the

maintenance and development of a highly skilled and clinically diverse multi-disciplinary

team. Particular attention will be given to targeting special population cohorts identified

within the model of care.

BPD Co clinicians will be provided with training and coaching to facilitate their roles as

agents of change within the LHNs, which will include providing supervision, coaching,

mentoring, consultation and training.

All BPD Co hub clinicians will be provided regular clinical supervision, coaching and

training opportunities in line with the individual’s development needs identified through

the performance review and development process.

All BPD Co staff will be required to undertake mandatory training in line with the

CHSALHN Training Policy.

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3.12.2. Tier 2: Training provided by BPD Co to others

˃ Mental Health Services and clinicians providing clinical services to consumers living with BPD, including networked clinicians

˃ Relevant non-mental health LHN services, PHN, GPs, private providers, NGOs, SAPOL and SAAS

˃ Consumer, carers and families; and

˃ The wider community

A range of training options will be available to the above cohorts over the staged

implementation period which will be detailed in the training plan.

All training and educational programs will be evaluated as part of the research and

quality assurance program. Outcome measures may include clinician core

competencies, improved clinical outcomes, and cultural change.

3.13. Research and Quality Assurance

The BPD Co will implement a research and quality assurance program with the aim of

ensuring that the services offered are appropriate, effective and efficient. An evaluation

and monitoring framework will be developed to capture information relating to the key

performance indicators outlined in the BPD Co Model of Care.

Quality assurance activities will also be undertaken to ensure that the BPD Co meets

relevant standards including:

˃ National Safety and Quality Health Service Standards v. 2

˃ National standards for mental health services

A BPD Co research plan will outline the implementation of research activities over the

course of the next three years. An innovative research program will be developed with

the aim of addressing gaps in the literature as outlined in the BPD Co Model of Care, SA

Mental Health Commission Action Plan for People living with BPD, and the Clinical

Practice Guideline for the Management of Borderline Personality Disorder (p. 133-134,

NMHRC, 2012). The BPD Co will promote opportunities for the integration of clinical and

academic research through collaboration with clinicians, academics, consumers and

carers. The research program will aim to contribute to, and complement, existing local

and national initiatives researching assessment, management, and support of

consumers with a diagnosis of BPD and their carers and families.

A PhD scholarship will be funded by the BPD Co with the focus directed on a priority

research area as outlined in the BPD Co research plan. Additional research projects will

be pursued through collaborative relationships with local tertiary institutions and through

applications for research grant funding where applicable. Hub and network staff will

support data collection relating to service activity and clinical outcomes. Consumers and

carers will have a vital role in influencing service evaluation through participation, clinical

outcome monitoring and feedback, as well as active participation in specific research

projects.

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3.13.1. Data Collection:

The BPD Co will aim to collect data via a number of mechanisms. Interventions provided

within mental health services will utilise the computer-based information system where

the service is physically located (i.e. CBIS or CCCME). Coding of services will be guided

by the service type and phase of the stepped care consumer pathway, to ensure that

data can be collated in a way that reflects the activity of clinicians across the hub-spoke

model.

A suite of assessment tools specific to the measurement of BPD and associated

features will be implemented to assess clinical outcomes and intervention effectiveness

and will be adapted according to the step-of-treatment, intervention-type, service setting,

and to take into consideration the needs of special populations. An evaluation

framework will be developed in line with the BPD Co Research Plan. The evaluation

framework will aim to maximise the clinical data obtained to ensure that evaluation is

meaningful and useful, while trying to minimise the burden on consumers and staff.

BPD Co will aim to seek feedback using the ‘Your Experiences Survey’ (YES) and

‘Carer Experiences Survey (CES)’ to monitor consumer and carer experiences of care in

line with recommendations made within the 5th National Mental Health and Suicide

Prevention Plan (Council of Australian Governments Health Council, 2018).

Finally, the state-wide BPD Co training and education program will provide activity data

and be evaluated for quality assurance. Outcomes may include measurement of

clinician core competencies, improved clinical outcomes, and cultural change.

Research ethics approval for specific projects will be sought when the triggers outlined

in the ‘Ethical Considerations in Quality Assurance and Evaluation Activities’ (NHMRC,

2014) are met. Given that BPD Co is a state-wide service, with different elements of

service located within LHN spokes, agreements regarding the access and sharing of

data will be established within the LSAs.

3.13.2. Data Reporting:

Outcomes of quality assurance and research activities will be reported through various

mechanisms:

˃ Service level reports

˃ Accreditation

˃ Conference presentations

˃ Peer-reviewed publications

There should be agreement as to what constitutes the work required for authorship on

such publications (e.g., see https://www.apa.org/research/responsible/publication/ ).