Wellness, Independence, Self-actualisation and Rehabilitation Program
1 August 2014 Last updated:
9 October 2014
The Wellness, Independence, Self-actualisation and Rehabilitation Program (WISAR)
Designing a model of care for the Mental Health Sub-Acute Unit
By Wagga Wagga Mental Health Sub-Acute Unit, Murrumbidgee Local Health District
The project aimed to design and implement a model of care for the Wagga Wagga Mental Health Sub-Acute Unit. The decision was made to design a new service model rather than adopt an existing model of care used by another District or service. The model created was based on feedback from consumers, families, carers, mental health staff and staff of other service partners. The model reflects the unique needs of the District. It is a product of what stakeholders within the Murrumbidgee Local Health District stated they value, are most likely to benefit from and are able to contribute towards.
Download a poster about this project from the Centre for Healthcare Redesign graduation, August 2014.
To design and implement a recovery-oriented and financially sustainable service that addresses a diverse range of rehabilitation needs for consumers admitted to the Wagga Wagga Mental Health Sub-Acute Unit by July 2015.
The development and implementation of a sound model of care for the sub-acute offers a range of benefits for consumers admitted to the Mental Health Sub-Acute Unit. These include:
- Improving the care experience and outcomes for mental health consumers
- Increasing the clinical capacity to intervene early in an episode of mental illness or relapse
- Improving the consumer experience of care by offering a range of time-limited programs designed to optimise personal, social, occupational and mental health functioning and create a greater focus on physical health and wellbeing. It is anticipated that the service model will contribute to improved demand management across the mental health service spectrum.
Commenced at Centre for Healthcare Redesign August 2013.
To date, Murrumbidgee Local Health District has lacked a designated mental health sub-acute unit. This has impacted on the quality of care offered to consumers who require admission to a sub-acute facility. There are wide gaps between the treatments indicated and those provided for this cohort of consumers, leading to repeated hospitalisations and poor health and mental health outcomes (NSW Ministry of Health 2009).At a District level consumers who require admission to a sub-acute facility have articulated that there is a distinct lack of therapeutic interventions offered in the Mental Health Acute Unit and a lack of involvement in treatment decisions.
The lack of sub-acute beds has placed a burden on acute inpatient facilities. The current model of acute service provision is not financially viable. The Wagga Wagga Mental Health Acute Unit was $1.42 million overspent for the 2012/2013 financial year.
The consequences of not conducting this research are a continuation in the provision of sub-optimal care for mental health consumers who require sub-acute care and a financially unsustainable mental health acute inpatient service.
Ten high priority solutions were identified which if successfully implemented will lead to the development of a recovery oriented and financially sustainable sub-acute service. An implementation working party was formed to progress the ten high priority solutions shown below (Figure 1). The Implementation Working Party meets fortnightly and will convene until 31 December 2014.
Eight of the ten high priority solutions have been completed or are nearing completion.
Figure 1. Solutions
Murrumbidgee Medicare Local (MMLL) Support Facilitator
Findings during the diagnostics phase lead to the solution of hosting a MML Support Facilitator. It was found that:
- care plans that included other services were not being completed
- the range of services that might be of benefit to a consumer’s recovery were not being identified
- there were opportunities to improve continuity of care and demand management across acute, sub-acute and community treatment settings.
As a result, a MML Partners in Recovery (PiR) Support Facilitator has been co-located in the Sub-Acute Unit to identify consumers with complex care needs who may benefit from accessing multiple services. This includes referral post transfer of care to the PiR program in the consumer’s community. To date eight consumers admitted to the Sub-Acute Unit have been referred to the PiR program.
Admissions and transfer of care committee
An admissions and transfer of care committee has been formed together with clearly defined eligibility criteria for the sub-acute unit. The function of the committee is to increase throughput from the acute and sub-acute units. The committee also manages referrals from the community to facilitate sub-acute admissions and reduce the demand for acute admissions by intervening earlier when consumers are becoming unwell.
Two key issues were identified during the diagnostics phase that led to the idea to develop an admissions committee and eligibility criteria. It was found that mental health consumers had access to inpatient care only when acutely unwell, and for the Mental Health Acute Unit to become financially viable it needed to increase throughput from the acute unit to other treatment settings.
Sub-acute staff have been provided with training in recovery oriented practice and principles and use of the Mental Health Recovery StarTM. Training was conducted to increase the capacity of front-line clinicians and managers to implement the new service model which includes a much broader focus to care than what has been traditionally provided by mental health services.
Group therapeutic and activity based programs for the unit have been implemented. During the diagnostic phase of the project, consumers and families reported that few programs were offered to consumers during an inpatient stay. Staff identified that the inpatient environment and processes did not support program delivery. They viewed the lack of programs as contributing to poor mental health outcomes including repeated hospitalization for the cohort of consumers who would potentially benefit from sub-acute care.
Rehabilitation Support Team
A Rehabilitation Support Team is allocated to each consumer upon entry to the Mental Health Sub-Acute Unit. This Team has responsibility for planning and coordinating care during the consumer’s inpatient stay and one clinician is assigned key responsibility for the overall care provided by the team. The Rehabilitation Support Team plays a role in preparing consumers for their return to the community. One of the functions of the team is to help each consumer to identify a primary worker in the community to which they will return (if not already identified). The Rehabilitation Support Team works in collaboration with the primary community worker to plan for the consumer’s transitioning to the community and enable continued care provision.
Rehabilitation Support Teams were proposed in response to the finding that ‘service coordination and integration of care’ was one of two domains identified by consumers, families and carers to most likely be associated with a negative care experience.
Comprehensive care plans
Comprehensive care plans that include other services are being completed for consumers admitted to the mental health sub-acute unit at weeks 2, 5 and 7 of their admission. Systems to support involvement of other services in care planning have been implemented and incorporated into operational procedures for the unit.
Peer Support Workers
Two Peer Support Workers with a lived experience of mental illness have been recruited to the unit in an effort to introduce a recovery focus to the sub-acute service and help facilitate meaningful cultural change.
Preliminary findings to date are outlined below.
- 12 Sub-acute beds have been operational since March 2014 with 25 admissions to the unit (to 30 June 2014) with 100% of consumers admitted meeting the eligibility criteria for the unit
- 100% of consumers were offered a choice from an array of rehabilitation activities
- 60% of consumers graduated from the program
- one consumer was re-admitted to the unit within 28 days following an episode of care in the acute inpatient unit
- Of those consumers who graduated from the program 86% demonstrated improvement when comparing HoNoS (Health of the Nation Outcome Scales) scores at time of admission and discharge.
- In contrast, only 33% of consumers who were admitted to the unit but did not complete the program demonstrated improvement on HoNoS scores during their admission.
A formative evaluation will be conducted to engage staff in identification of improvement strategies and refine the sub-acute unit service model. The formative evaluation is scheduled for December 2014.
An evaluation to assess the overall effectiveness or success of the Mental Health Sub-Acute Unit Model of Care in producing sustained change (i.e. achieving short, intermediate and long-term outcomes) will be conducted 2 years post-commencement of the sub-acute initiative.
A key learning from the project was to never under-estimate the importance of stakeholder consultation and collaboration. A particular strength of this project was the high level of commitment demonstrated by a number of partners both internal and external to the District as well as Mental Health consumers and their families.
The project also highlighted the benefit of visiting other contemporary and innovative facilities when designing a new service model. Lessons learned from other services enabled strategies to be put in place to mitigate likely future challenges prior to their emergence.
Both a limitation and strength of the project was the inability to map an existing process or service. The limitation was the inability to access valid and reliable baseline data given the lack of an existing sub-acute service. The strength was the opportunity to engage staff in implementation of a new service model quite unlike any existing model within the District concurrent with the building of a new facility.
A potential learning for the District is the need to recognise the importance of investing in project implementation. Sufficient resources are often assigned to projects in their formation and development but with insufficient resources, time and support committed to project implementation and evaluation. This makes for an incomplete cycle of quality improvement.
To date, outcomes from the Sub-acute model of care project are very promising and indicate that consumers are benefitting from the program. The program is nevertheless in its infancy and results will need to be replicated over time.
The development of the Mental Health Sub-Acute Model of Care included a high level of stakeholder engagement. A number of service partners contributed to the development of the model including:
- Murrumbidgee Medicare Local
- Schizophrenia Fellowship
- Carer Assist
- Mental health consumers, families and carers.
The Murrumbidgee Local Health District would like to acknowledge the contributions from Hunter New England and Western Local Health Districts. Site visits to the Intermediate Stay Mental Health Unit and Dubbo Mental Health Rehabilitation and Recovery Centre proved invaluable and helped shape the service model developed.
Anthony, W. 2000, ‘A recovery oriented service system: setting some system level standards’ Psychiatric Rehabilitation Journal; vol. 24, No2, p 159 -168.
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Mental Health Council of Australia, 2010, ‘National Mental Health and Hospital Networks, COAG and Mental Health Reform: Sub-Acute Care Initiative Position Paper’, viewed 5 August 2013, www.mhca.org.au/index.php/component/rsfiles/download-file?path=Health%20Reform/MHCA%20Position%20Paper%205%20-%20Sub-acute%20Care%20Initiative.pdf&Itemid=553
NSW Department of Health, 2008b, ‘NSW community mental health strategy 2007-2012: From Prevention and early intervention to recovery’, Better Health Centre Publications: Sydney.
NSW Ministry of Health, 2009, ‘Physical Health Care of Mental Health Consumers Guidelines’, Better Health Centre Publications, Sydney.
Pearce, S and Farrell, A 2010 ‘Strategic Rehabilitation Plan: Greater Southern Area Health Service, December 2010-December 2013’ (internal document/unpublished report).
Triangle Consulting Social Enterprise Limited and the Mental Health Providers Forum. 2009. Mental Health Recovery Star. Retrieved from www.outcomesstar.org.uk/mental-health 7 August 2014.
Coordinator Partnerships and Rehabilitation, Mental Health and Drug and Alcohol Service
Murrumbidgee Local Health District
Phone: 02 6456 1473
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