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NSW Forensic Patient Needs and Services Project

Justice Health and Forensic Mental Health Network
Project Added:
4 May 2015
Last updated:
18 May 2015

NSW Forensic Patient Needs and Services Project

Summary

This project conducted a detailed examination of forensic mental health services in NSW and assessed the needs of current forensic patients, to see whether they are being met. This information will inform the need for service reform and development. 

Aim

To assess the therapeutic security characteristics of residential placements available to forensic mental health patients and evaluate whether these services are meeting their needs.

Benefits

  • Identifies potential gaps in service provision at an individual and systemic level.
  • Informs future service planning.
  • Develops systems to allocate forensic patients to a suitable level of therapeutic security.
  • Enhances forensic patient recovery.
  • Assists benchmarking.

Project Status

Project status: Implementation - this initiative is ready for implementation, is currently being implemented, piloted or tested.

Project dates: March 2014 - March 2015

Background

Prior to the establishment of the Justice Health & Forensic Mental Health Network (JH&FMHN) in 2013, forensic mental health services in NSW were developed under the direction of local mental health services. In NSW, forensic patients are placed across a range of community, inpatient, and correctional settings, under the governance of Local Health Districts (LHDs).

The majority of forensic patients in hospital are placed in high security, followed by three ‘medium secure’ units in LHD hospitals. More than 100 forensic patients are placed in the community, in a variety of accommodations. There has been a steady increase in the number of forensic patients in NSW, which has placed pressure on hospital beds, community placements and patient flow.

No mapping of forensic mental health services has been conducted to date in NSW. This means there is limited knowledge on the kind of support available to forensic patients, other than in ‘high’ and ‘medium’ secure care. There are also significant unknowns regarding the therapeutic security characteristics of forensic mental health services.

The assessment of a patient’s needs has long been recognised as an essential, core component of health service planning and delivery. More recently, the important differences of forensic patient needs have been highlighted and literature describing the needs of forensic patients now exists across different jurisdictions. However, no comprehensive study has been conducted evaluating the needs of the forensic patient cohort in NSW.

Implementation 

  • The lead clinician at each site will be contacted to discuss the project background, aims and benefits. These will be outlined in a standard ‘Project Information Sheet’ along with a point of contact for each site.
  • Key staff from each site will form an expert group, to evaluate each residential placement and complete the forensic patient needs assessment. It is anticipated that members of the group will comprise of staff from a range of disciplines, such as nurse unit manager, lead psychiatrist and member of allied health. The lead clinician will decide the minimum number of clinicians in the expert group, ensuring adequate coverage of topics to be addressed.
  • A meeting with the expert group will take place at each site, to discuss each patient and complete the assessment.
  • All data collected will be de-identified and no names will appear on any of the documentation.
  • The expert group will be chaired by a member of the project team, who will offer their expert working knowledge of the assessment tools.

Implementation sites

  • All NSW Health in-patient units and correctional centres
  • Long Bay Psychiatric Hospital
  • JH&FMHN Community Forensic Mental Health Service

Evaluation 

Evaluation of therapeutic security characteristics of residential placements

  • Demographic information will be collected for each placement, including number of beds, number of current forensic patients and staffing profile. This data will be entered into the ‘Data Collection Sheet - Placement’.
  • The therapeutic characteristics of community placements (all placements not considered an in-patient unit or supported accommodation) and correctional centres will not be evaluated. Examples of community placements that will not be evaluated include a patient’s own residence and a hostel with no dedicated support staff.

The following instruments will be used:

  1. The Security Needs Assessment Profile (SNAP) will be utilised to assess the therapeutic security characteristics of each placement. The SNAP provides a systematic framework to examine security across open, low, medium and high-security forensic mental health services. The SNAP examines the three traditional dimensions of security: physical, procedural and relational. Each dimension is subdivided into a number of items, with 22 items overall. Each item will be discussed and rated by the expert group. This data will be entered into the ‘Data Collection Sheet - Placement’, prior to analysis using the Statistical Package for the Social Sciences (SPSS).
  2. The See Think Act Scale (STA Scale) will be utilised to further evaluate the relational security dimension. It contains 28 items rated on a four-point Likert scale. The STA Scale has shown to be a reliable measure of relational security. Members of the expert group will be asked to complete the STA Scale. All members of staff in the unit at the time of the expert group will be provided with a ‘Project Information Sheet - STA Scale’ and if they consent, will complete the STA Scale. The data will be entered in to a spreadsheet, prior to analysis using SPSS.

Assessment of forensic patient needs

  • The expert group will be guided through a needs assessment discussion about each forensic patient residing at that placement on the census date.
  • Procedurally, forensic patients considered will be allocated a unique study number; all data collected will be completely de-identified.
  • The data will be entered into the ‘Data Collection Sheet - Patient’ prior to analysis using SPSS. The project team will not be making an assessment of the opinion of the expert group. The project team will seek clarification of item scoring prior to documenting the score.
  • A range of forensic patient needs will be assessed using validated instruments, from the perspective of the staff members on that unit who form the expert group. Members of the expert group will be asked to rate each item in the instruments and may refer to the patient medical record to guide their ratings; they routinely have access to patient files for the purposes of fulfilling their primary role with the service or unit. No member of the project team will have access to the patient medical records at any point during this process.

The following instruments will be used:

  1. Dangerousness, Understanding, Recovery and Urgency Manual (DUNDRUM)
  2. Forensic Version of the Camberwell Assessment of Need (CANFOR)
  3. Historical Clinical Risk Management-20 V3 (HCR-20).

Lessons Learnt

  • Understanding a new methodology for project design and implementation.
  • The coordination of a complex project with many players.
  • The importance of communication.

Evidence Base

  1. Collins M, Davies S. The Security Needs Assessment Profile: A Multidimensional Approach to Measuring Security Needs. International Journal of Forensic Mental Health 2005; 4(1): 39-52.
  2. Collins M, Davies S, Ashwell C. The Security Needs Assessment Profile, Version 4.12007; 2005.
  3. Davies S, Collins M, Ashwell C. Validation of the Security Needs Assessment Profile (SNAP) by a national survey of secure units in England. The Psychiatrist 2012; 36(10): 366-71.
  4. McClean R.J. Assessing the security needs of patients in medium secure psychiatric care in Northern Ireland. The Psychiatrist 2010; 34(10): 432-6.
  5. Tighe J, Gudjonsson GH. See, Think, Act Scale: Preliminary development and validation of a measure of relational security in medium and low-secure units. The Journal of Forensic Psychiatry & Psychology 2012; 23(2): 184-99.
  6. Kennedy HG, O'Neill C, Flynn G, Gill P. The Dundrum Toolkit. Dangerousness, Understanding, Recovery and Urgency Manual (The Dundrum Quartet). Four Structured Professional Judgement Instruments for Admission Triage, Urgency, Treatment Completion and Recovery Assessments. Dublin, Ireland: Trinity College Dublin; 2010.
  7. Davoren M, Abidin Z, Naughton L, Gibbons O, Nulty A, Wright B, et al. Prospective study of factors influencing conditional discharge from a forensic hospital: the DUNDRUM-3 programme completion and DUNDRUM-4 recovery structured professional judgement instruments and risk. BMC Psychiatry 2013; 13:185. PubMed PMID: 23837697. Pubmed Central PMCID: PMC3710275. Epub 2013/07/11.
  8. Davoren M, O'Dwyer S, Abidin Z, Naughton L, Gibbons O, Doyle E, et al. Prospective in-patient cohort study of moves between levels of therapeutic security: the DUNDRUM-1 triage security, DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales and the HCR-20. BMC Psychiatry 2012; 12: 80. PubMed PMID: 22794187. Pubmed Central PMCID: PMC3434023. Epub 2012/07/17.
  9. Flynn G, O'Neill C, Kennedy HG. DUNDRUM-2: Prospective validation of a structured professional judgment instrument assessing priority for admission from the waiting list for a forensic mental health hospital. BMC Res Notes 2011; 4:230. PubMed PMID: 21722397. Pubmed Central PMCID: PMC3224499. Epub 2011/07/05.
  10. Flynn G, O'Neill C, McInerney C, Kennedy H.G. The DUNDRUM-1 structured professional judgment for triage to appropriate levels of therapeutic security: retrospective-cohort validation study. BMC Psychiatry 2011; 11:43. PubMed PMID: 21410967. Pubmed Central PMCID: PMC3066108. Epub 2011/03/18.
  11. O'Dwyer S, Davoren M, Abidin Z, Doyle E, McDonnell K, Kennedy HG. The DUNDRUM Quartet: validation of structured professional judgement instruments DUNDRUM-3 assessment of programme completion and DUNDRUM-4 assessment of recovery in forensic mental health services. BMC Res Notes 2011; 4:229. PubMed PMID: 21722396. Pubmed Central PMCID: PMC3146857. Epub 2011/07/05.
  12. Thomas S, Harty MA, Parrott J, McCrone P, Slade M, Thornicroft G. The Forensic CAN: A needs assessment for forensic mental health service users. London: Gaskell; 2003.
  13. Thomas S, Leese M, Dolan M, Harty MA, Shaw J, Middleton H, et al. The individual needs of patients in high secure psychiatric hospitals in England. The Journal of Forensic Psychiatry & Psychology 2004; 15(2): 222-43.
  14. Douglas KS, Hart SD, Webster CD, Belfrage H. HCR-20V3: Assessing risk of violence – User guide. Burnaby, Canada: Mental Health, Law, and Policy Institute, Simon Fraser University; 2013.

Contact

Jonathon Adams
Staff Specialist Forensic Psychiatrist
Justice Health & Forensic Mental Health Network
Phone: 02 9700 3292
Email: jonathon.adams@justicehealth.nsw.gov.au

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