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T-MOP Together for the Mental health of Older People A network project on the Southern Fleurieu and Kangaroo Island Region

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Partners Southern Adelaide-Fleurieu-Kangaroo Island Medicare Local Southern Fleurieu and Kangaroo Island Positive Ageing Task Force Country Health SA Local Health Network Mental Health Services Flinders University

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The problem Mental health issues in the older population are frequently associated with co-morbidities Access to care can be difficult multiple services different views on care responsibilities Collaboration between services is needed because of complexity of needs

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Project questions 1. What organisational linkages currently exist in a rural region for the provision of mental health care for older people? 2. What are the gaps, barriers and enablers in linking services, as perceived by key stakeholders, consumers and their carers? 3. What linkages could be established between services for the mental health care of older people? 4. What network planning and management model would be practical for providing mental health care to older people?

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What will happen

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Who we interviewed Aged Care/Community services Primary Care/General Health Mental Health/Dementia Care Victor Harbor/Goolwa Residential Facility Caring Neighbourhood Programme Alexandrina Centre for Positive Ageing ECH Therapy Programmes Gospel Centre Medical Practice Goolwa Medical Practice Victor Harbor Community Health Private mental health worker South Coast District Hospital Mental Health Service Dementia Services 14 Yankalilla ACH Community ServicesMedical Practice 2 Kangaroo Island Community Health Medical Practice Mental Health Service3 Strathalbyn Carer Wellness CentreMedical Practice Strathalbyn Community Health Mental health Service4 Regional Positive Ageing TaskforceSAFKI Medicare Local Aged Care Assessment Team 3 Total 26

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Local Level Suggested opportunities for change: Formalise a feedback mechanism about client referrals between community aged care services and GPs to promote consistency of communication e.g. development of a template for use by different organisations. Provision of an educational program facilitated by Nurse Practitioners or Clinical Practice Consultants to educate agencies on the importance on providing feedback, including identifying who should be included in this process. Setting up a virtual meeting space to share resources and local knowledge about what services are available and eligibility, and for a library of resources. It was considered that actions at level 1 could be achieved with current resources.

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Management Level Suggested opportunities for change: Up skilling support workers to identify and report decline in older peoples function & mental state. It was noted, however, that since 2011 the Positive Ageing Taskforce has run a number training courses and so the issue might be to determine continued need and approaches to this.. Engage leadership at higher levels to support workers participation in beneficial networking activities (eg important committees & meetings). Shared electronic case notes across disciplines/services. Increased access to psycho-geriatricians (including via video conferencing) and geriatricians/memory clinics in local hospitals.

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Management Level cont. Suggested opportunities for change: Consider the roles, current resources and organisations appropriate to provide assessment and sign-posting of referrals for older people across a range of mental health and related problems that are dealt with by RCFs, GPs and other services. Acknowledge those staff with important local network leadership functions by recognising this in their role. Actions at level 2 require champions to work with management and focus on specific, do-able and relatively sustainable actions within the constantly changing policy environment.

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Policy and Funding Level Suggested opportunities for change: Broaden use of MOUs to facilitate effective linkages e.g. use MOUs between aged care package providers and referring agencies to require that feedback occur after the referral. Local government provide a voice for aged care and mental health issues when developing local health plans. Lobby policy makers regarding the limitations of the current Medicare funding model e.g. limits on the role of the practice nurse as case manager and GPs ability to attend care planning meetings. Actions at level 3 would require connections with existing older persons lobby groups to put mental health on their agenda.

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What next? Road show presentation to individual services/groups Client Journey interviews Senior Leaders interviews Final workshop 20 th November

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Social Media Updates Flinders University blog address: http://blogs.flinders.edu.au/tmop/ SAFKI Medicare Local twitter account: @safkiml