How access has changed emergency mental health care in the ... · How access has changed emergency...
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How access has changed emergency mental health care in the bush Emily Saurman Broken Hill University Department of Rural Health
Transcript of How access has changed emergency mental health care in the ... · How access has changed emergency...
How access has changed emergency mental health care in the bush
Emily Saurman Broken Hill University Department of Rural Health
Presenter
Presentation Notes
Good afternoon Thank you for this opportunity to participate in this series. I have spent the last few years conducting an evaluation of a telepsychiatry program called the Mental Health Emergency Care-Rural Access Program or MHEC-RAP or MHEC for short. Today I’m going to speak to you about one study within the evaluation, but first a bit of background.
the Mental Health Emergency Care- Rural Access Program (MHEC-RAP/MHEC)
• to improve ACCESS, safety, and service coordination to specialist MH care
• providing Information and Emergency Clinical Services via telehealth
55% of the state
Presenter
Presentation Notes
In Australia, a well serviced rural town might have a psychiatrist visit once-a-month with more frequent visits from a mental health nurse, but many have no resident access to mental health specialists. MHEC was developed to improve access to specialist emergency mental health care in rural and remote communities. We know that patients who can receive appropriate care locally will fare better and that access to specialist care, would not only reduce patient distress and benefit outcomes, but facilitate the effective use of already limited resources. Telehealth systems respond to difficulties of remoteness such as vast distances and a limited workforce. ^MHEC uses telehealth technology to provide general information services and emergency clinical services such as telephone triage and video assessments. These services are provided for all providers, patients, and residents across the Far West and Western NSW Local Health Districts (the two areas identified on the map). These two health districts serve approximately 300,000 residents living across regional, remote, and very remote countryside.
the evaluation
METHODOLOGY • Case Study METHOD • Multiple methods
PROGRAM AIMS • Improve access to
care • Improve safety • Improve service
coordination
Presenter
Presentation Notes
Overall, the evaluation of MHEC is a case study conducted in two stages using multiple methods to assess the program aim of improving access to care. This evaluation was designed to: identify and describe program activity, describe the provision of emergency mental health care through MHEC, assess program impact and influence on improving access, and inform further program development and transferability. The same lens was applied to the analysis for each study. That lens is the theory of access.
THEORY
Penchansky, R. and J. W. Thomas (1981). "The Concept of Access: Definition and Relationship to Consumer Satisfaction." Medical Care 19(2): 127-140.
Presenter
Presentation Notes
The theory of access was applied across the evaluation. Penchansky and Thomas defined access to be the degree of fit between the consumer and the service – the better the fit, the better the access. They proposed that access was central to health services and that access incorporated five concepts, I included a sixth – awareness. I believe that awareness has become an assumed concept when it comes to health care services, but is actually quite important. Each concept is independent yet interconnected. A service can be accessible and affordable and tick every other box, but is only available on Wednesday afternoons thereby limiting access.
the study
METHOD • Semi-structured
interviews • Analysed data
through lens of the 6 concepts of access
AIMS • Understand impact
of MHEC through the experience of consumers
• Identify matters for implementation
Presenter
Presentation Notes
When we think of health service consumers, we usually think of the patients, but MHEC is a service that provides access to local providers as well. This study is a collection of interviews with 12 local emergency department providers from across the region about their use and experience of emergency mental health care and MHEC. I interrogated these interviews against the 6 concepts of access to identify the impact of MHEC and used their experience to inform further program development and considerations for implementation for other regions and populations. Although they did not speak to the 6 concepts directly or explicitly, all six concepts were discussed. Now we’re going to go through each concept – I will present the information from the interviews and then the implications for implementation.
Accessibility (proximity to the consumer in time and distance)
Able to get immediate assistance without waiting or travelling
• “It makes such a difference being able to have somebody on the other end of the phone”
• “When somebody comes in, they’re reviewed, they’re assessed, they’re immediately talking to MHEC-RAP”
Presenter
Presentation Notes
MHEC was accessible to each of these emergency department providers because it provided timely care and assistance no matter how remote you might be. Local providers were able to access specialist care without having to wait for a specialist to come to them and their patients didn’t have to be sent away to receive the specialist care they needed. So for instance in one hospital “when somebody comes in, they’re reviewed, they’re assessed, they’re immediately talking to MHEC-RAP” ^But when considering the accessibility of this or a similar service for implementation elsewhere, it is more about contextual considerations like regional accessibility to a telephone and mobile service or how many locations will have a video system and where the systems should be located. These variables need to be established before you can start providing services. For example, MHEC provides video assessments through links established in the hospital facilities across the region rather than in a general surgery or patient home to enable access for the patient to systems and other resources that may be needed in an emergency situation.
Accessibility (proximity to the consumer in time and distance)
IMPLICATIONS for IMPLEMENTATION
• Considerations of context –Requires access to telephone for basic
service –Video access points
• Number and distribution of equipment
Presenter
Presentation Notes
MHEC was accessible to each of these emergency department providers because it provided timely care and assistance no matter how remote you might be. Local providers were able to access specialist care without having to wait for a specialist to come to them and their patients didn’t have to be sent away to receive the specialist care they needed. So for instance in one hospital “when somebody comes in, they’re reviewed, they’re assessed, they’re immediately talking to MHEC-RAP” ^But when considering the accessibility of this or a similar service for implementation elsewhere, it is more about contextual considerations like regional accessibility to a telephone and mobile service or how many locations will have a video system and where the systems should be located. These variables need to be established before you can start providing services. For example, MHEC provides video assessments through links established in the hospital facilities across the region rather than in a general surgery or patient home to enable access for the patient to systems and other resources that may be needed in an emergency situation.
(resources to meet volume and need)
Responding to need for specialist care – for the patient – for the provider
Ease the demand upon local providers
• “Before MHEC-RAP, patients used to sit in emergency departments for much, much longer with no definitive care”
Presenter
Presentation Notes
MHEC-RAP made specialists available to respond to local emergency needs. Even when a specialist is in town, they may have full appointment schedules and are not always available to respond to provide emergency assistance when it is needed. So for example, MHEC can be contacted by telephone or video from emergency departments across the region, there are always two MHEC staff available at any hour to provide assistance. MHEC-RAP was not only providing care to meet the needs of the presenting patients, but was also responding to and supporting the local providers in their clinical decision making and provision of care. The difficulty for implementation is to balance program responsiveness with efficiency and to ensure that the program will be available when it is needed.
(resources to meet volume and need)
IMPLICATIONS for IMPLEMENTATION
• Range of services • Balance responsiveness and efficiency
– Staff – Technology
Presenter
Presentation Notes
MHEC-RAP made specialists available to respond to local emergency needs. Even when a specialist is in town, they may have full appointment schedules and are not always available to respond to provide emergency assistance when it is needed. So for example, MHEC can be contacted by telephone or video from emergency departments across the region, there are always two MHEC staff available at any hour to provide assistance. MHEC-RAP was not only providing care to meet the needs of the presenting patients, but was also responding to and supporting the local providers in their clinical decision making and provision of care. The difficulty for implementation is to balance program responsiveness with efficiency and to ensure that the program will be available when it is needed.
Acceptability (consumer perception)
Not perfect…BUT… Changing practice and improving confidence Reducing crises
• “MHEC-RAP has basically reduced the crisis.
…we can actually get the process happening straight away and everything just calms down”
Presenter
Presentation Notes
Although it was said that MHEC-RAP was not the perfect solution in every case, it was clearly acceptable. MHEC-RAP was considered to be helpful and supportive, it improved provider confidence to manage care locally, reduced the local crises by providing timely and relevant assistance, and it was easy to use. Local providers also reported an acceptance by the patients in that they were able to see a specialist for help without having to wait or travel “…we can actually get the process happening straight away and everything just calms down”. One thing that helped engagement was that the service was regionally located and had conducted site visits to get a picture and understanding of each community in the region. This was important because it connected with the local clinicians and gave a face to the voice on the other end of the telephone line. It also helped to maintain information sharing so that patient referrals to see a visiting specialist aligned with when that specialist was actually in town and even who that specialist might be (whether it is psychiatrist or a community mental health team member). An acceptable service knows what the local circumstances are and therefore provides relevant referrals and useful assistance.
Acceptability (consumer perception)
IMPLICATIONS for IMPLEMENTATION
• Considerations of context – Regionally located – Specific populations
• Access – Range of services – Effective referral pathways – User-friendly and safe technology
Presenter
Presentation Notes
Although it was said that MHEC-RAP was not the perfect solution in every case, it was clearly acceptable. MHEC-RAP was considered to be helpful and supportive, it improved provider confidence to manage care locally, reduced the local crises by providing timely and relevant assistance, and it was easy to use. Local providers also reported an acceptance by the patients in that they were able to see a specialist for help without having to wait or travel “…we can actually get the process happening straight away and everything just calms down”. One thing that helped engagement was that the service was regionally located and had conducted site visits to get a picture and understanding of each community in the region. This was important because it connected with the local clinicians and gave a face to the voice on the other end of the telephone line. It also helped to maintain information sharing so that patient referrals to see a visiting specialist aligned with when that specialist was actually in town and even who that specialist might be (whether it is psychiatrist or a community mental health team member). An acceptable service knows what the local circumstances are and therefore provides relevant referrals and useful assistance.
Affordability (cost for the service and consumer)
No known cost Perceived savings in unnecessary transportations for the Service and Patient
• “MHEC-RAP’s actually saved us money, a lot of
money in transport fees”
Presenter
Presentation Notes
The providers did not have to pay to use the program, in fact they saw only savings. Money was seen to be saved in reducing the number of unnecessary patient transportations (which can be quite costly –financially emotionally and in time– when it can take 2-3 days to transport a patient from a remote community by ambulance with police and nurse escorts) – the savings also extended to the patient and their family in the costs for visitation and the necessary cost of travel for a patient to return home after they’ve been sent to an inpatient unit. Because MHEC-RAP can be contacted via a freecall telephone number anyone with access to a telephone can call them without charge. The use of existing telehealth systems and technology to establish the video service in the emergency departments is also something to consider for implementation, this can limit the initial costs and from this starting point, systems may be upgraded or new systems later installed. We have indirect evidence that over time, more of the patients that receive care through MHEC-RAP are being managed locally. This is from indirect evidence of experience and the trend within the program activity data.
Affordability (cost for the service and consumer)
IMPLICATIONS for IMPLEMENTATION
• Use of pre-existing technology –Freecall number and telehealth network
• New technology rolled out
• Change in care provision
Presenter
Presentation Notes
The providers did not have to pay to use the program, in fact they saw only savings. Money was seen to be saved in reducing the number of unnecessary patient transportations (which can be quite costly –financially emotionally and in time– when it can take 2-3 days to transport a patient from a remote community by ambulance with police and nurse escorts) – the savings also extended to the patient and their family in the costs for visitation and the necessary cost of travel for a patient to return home after they’ve been sent to an inpatient unit. Because MHEC-RAP can be contacted via a freecall telephone number anyone with access to a telephone can call them without charge. The use of existing telehealth systems and technology to establish the video service in the emergency departments is also something to consider for implementation, this can limit the initial costs and from this starting point, systems may be upgraded or new systems later installed. We have indirect evidence that over time, more of the patients that receive care through MHEC-RAP are being managed locally. This is from indirect evidence of experience and the trend within the program activity data.
Adequacy (organisation)
Program structure/function – 24/7 – No wrong door – Use of technology
Responded to inadequacy of local access afterhours and on weekends
• “Having MHEC-RAP now 7 days-a-week,
24 hours-a-day is brilliant”
Presenter
Presentation Notes
MHEC-RAP was adequate in its simple design and has provided access to a resource that addressed a need. Even for those communities that had visiting specialists or resident community mental health teams, the need for assistance afterhours and between visits was clearly stated and MHEC was filling that void. In a few communities, there was contention around the location of the MHEC-RAP video equipment within the emergency department or the particular model installed, for instance whether the video equipment was a wall-mounted set up or a transportable desktop system. But this is something that can and would need to be negotiated for continued program development and implementation of the program. MHEC offers a straightforward model for implementation or adaptation elsewhere.
Adequacy (organisation)
IMPLICATIONS for IMPLEMENTATION
• Consideration of context • Program structure and function • Negotiation regarding location and model of
video equipment
Presenter
Presentation Notes
MHEC-RAP was adequate in its simple design and has provided access to a resource that addressed a need. Even for those communities that had visiting specialists or resident community mental health teams, the need for assistance afterhours and between visits was clearly stated and MHEC was filling that void. In a few communities, there was contention around the location of the MHEC-RAP video equipment within the emergency department or the particular model installed, for instance whether the video equipment was a wall-mounted set up or a transportable desktop system. But this is something that can and would need to be negotiated for continued program development and implementation of the program. MHEC offers a straightforward model for implementation or adaptation elsewhere.
Awareness (communication and information)
Basic knowledge of program – 24hours – Regional team
Flexibility in the model for local adaptation – Variation in need; support vs standard
practice – Complement to existing systems/practice
• “It helps when you know about it … it does become your best friend … we use it a lot”
Presenter
Presentation Notes
Now why did I modify the theory to include awareness? Because it was made quite clear to me during an initial study of this program 6 years ago, that awareness is vital to the effectiveness of this (and I argue) any health service program. no health service can be effective if the consumers are not aware it exists, what it is, how to use it, why they would use it, and so on… While there is still work to do, MHEC-RAP is making itself known. There was only one provider out of the 12 that had not heard of MHEC-RAP prior to our interview (and that person was new to the region). And a few of the providers even saw it as their role to teach others locally about the program because as one said “it helps when you know about it … it does become your best friend …we use it a lot” The flexibility I list there on the slide reflects the internal awareness of the program and its adaptability to local need – being accessible and available for those providers who contact MHEC-RAP with every mental health presentation that comes through the ED to those who use it to back up or verify their clinical decisions and patient management. In order for the program to continue to provide access to specialist emergency mental health care, there is a need to provide regular program promotion to ensure awareness and understanding. Awareness from both sides, the external and the internal.
Awareness (communication and information)
IMPLICATIONS for IMPLEMENTATION
• Considerations of context – Community resources and information – Current practice – Specific populations
• Program promotion – Regular contact with consumers
Presenter
Presentation Notes
Now why did I modify the theory to include awareness? Because it was made quite clear to me during an initial study of this program 6 years ago, that awareness is vital to the effectiveness of this (and I argue) any health service program. no health service can be effective if the consumers are not aware it exists, what it is, how to use it, why they would use it, and so on… While there is still work to do, MHEC-RAP is making itself known. There was only one provider out of the 12 that had not heard of MHEC-RAP prior to our interview (and that person was new to the region). And a few of the providers even saw it as their role to teach others locally about the program because as one said “it helps when you know about it … it does become your best friend …we use it a lot” The flexibility I list there on the slide reflects the internal awareness of the program and its adaptability to local need – being accessible and available for those providers who contact MHEC-RAP with every mental health presentation that comes through the ED to those who use it to back up or verify their clinical decisions and patient management. In order for the program to continue to provide access to specialist emergency mental health care, there is a need to provide regular program promotion to ensure awareness and understanding. Awareness from both sides, the external and the internal.
before MHEC-RAP • Limited access
– Providers felt alone
• Mental health emergencies were difficult to manage – Sedate and send
MHEC-RAP has • Provided access to
specialist care – Considerations of
context
• Changed local practice and perspective – Local care
Presenter
Presentation Notes
Essentially, before MHEC-RAP, access to specialist assistance was limited to the point that local providers felt alone and mental health emergencies were perceived to be difficult because they lacked the confidence the training the time or the help to care for these patients, leaving many to be simply sedated and sent to the nearest mental health inpatient unit. MHEC-RAP has since not only provided access to mental health specialists for emergency presentations, but it has changed the local practice and perspective around mental health care provision in emergency departments and need for specialist care. More providers are willing to manage and care for a patient locally before sending them away because they have MHEC.
[MHEC-RAP’s] a fantastic service because we’ve got quite a large mental health population and …
prior to this you kind of felt like you were flying blind; despite the fact
that we [see] a lot of [mental health]. I think MHEC-RAP has
changed the face of mental health in the bush. –remote ED nurse
Presenter
Presentation Notes
This is just a great example of that before and after experience. Even though mental health presentations are not rare, they felt as though they were flying blind. MHEC has changed that and they now have a resource to meet their need (whether that is for a navigation system or a co-pilot)
in summary
• Access is a universal concern • Access to specialist mental health care is
limited (particularly in rural and remote communities)
• MHEC-RAP has improved access to specialist care and changed practice for these providers and communities
• MHEC-RAP is a practical solution for improving access and changing the provision of care elsewhere.
Presenter
Presentation Notes
MHEC provides timely specialist emergency mental health care and support for communities that usually have limited or no access to such care. The MHEC model is a practical solution for improving access to specialist emergency mental health care. It is important to consider the regional context and all 6 concepts of access when designing and implementing telepsychiatry and other health care services. As an aside, this program and our evaluation findings have already informed program development and attracted the attention of other regions in Australia interested in implementing emergency telepsychiatry programs.
THANK YOU Acknowledgements: Interview participants, Centre of Research Excellence in Rural and Remote Primary Health Care, and My co-authors: Sue Kirby and David Lyle
For more information contact: Emily Saurman [email protected]
Publications from the Thesis(to date):
-Saurman, E., D. Lyle, D. Perkins and R. Roberts (2014). "The successful provision of emergency mental health care to rural and remote NSW-an evaluation of the Mental Health Emergency Care-Rural Access Program." Australian Health Review 38(1): 58-64. -Saurman, E., D. Lyle, S. Kirby and R. Roberts (2014). "Use of a mental health emergency care-rural access programme in emergency departments." Journal of Telemedicine & Telecare 20(6): 324-329. -Saurman, E., D. Lyle, S. Kirby and R. Roberts (2014). "Assessing program efficiency - a time and motion study of the Mental Health Emergency Care-Rural Access Program in NSW Australia." International Journal of Environmental Research and Public Health 11(8): 7678-7689. -Saurman, E., J. Johnston, J. Hindman, S. Kirby and D. Lyle (2014). "A transferable telepsychiatry model for improving access to emergency mental health care." Journal of Telemedicine & Telecare 20:391-399. -Saurman, E., S. Kirby and D. Lyle (2015). "No longer ‘flying blind’ - how access has changed emergency mental health care in rural and remote emergency departments-a qualitative study.“ BMC Health Services Research in review.
