Key Features Of The Model Of Care - NSW Health
NSW Older People’sMental Health Community ServicesKey Features of theModel of Care
NSW Ministry of Health100 Christie StreetST LEONARDS NSW 2065Tel. (02) 9391 9000Fax. (02) 9391 9101TTY. (02) 9391 9900www.health.nsw.gov.auProduced by: NSW Ministry of HealthThis work is copyright. It may be reproduced in whole or in part for study or trainingpurposes subject to the inclusion of an acknowledgement of the source. It may not bereproduced for commercial usage or sale. Reproduction for purposes other thanthose indicated above requires written permission from the NSW Ministry of Health.The NSW Ministry of Health acknowledges the traditional custodians of the landsacross NSW. We acknowledge that we live and work on Aboriginal lands. We pay ourrespects to Elders past and present and to all Aboriginal people. NSW Ministry of Health 2020SHPN (MH) 200008ISBN 978-1-76081-337-6Further copies of this document can be downloaded from the NSW Health webpagewww.health.nsw.gov.auJanuary 2020iiNSW HealthOPMH – Key Features of the Model of Care
ContentsModel of Care at a Glance. 3Introduction.41Philosophy of care, target population and functions. 62Partnerships. 73Working in different settings and in different ways. 74Key processes. 75Techniques and therapies. 86Staffing, leadership, clinical supervision & workforce development. 87Performance . 9Appendix A: Example resources to guide OPMH clinicians. 10Appendix B: Poster summary of Model of Care.11References.12NSW HealthOPMH – Key Features of the Model of Care1
This document presents the key features of the NSW SpecialistMental Health Services for Older People (SMSHOP) CommunityServices Model of Care (MoC). SMHSOP is now referred to asOlder People’s Mental Health (OPMH) services.This is a companion document to NSW Older People’s MentalHealth Community Services: Good practice recommendations forOPMH services and clinicians.The full version of the Model of Care is available on the NSWHealth website (GL2017 003).2NSW HealthOPMH – Key Features of the Model of Care
Model of care at a glanceRecovery-oriented, person-centred, biopsychosocial carewith the consumer, their carer and their GP.All sections listed on this page refer to sections of the full version of the Model of Care,as available on the NSW Health website (GL2017 003)Our targetpopulationPotential community OPMH service consumer and carer in the community(including RACFs) or other health care setting (including OPMH AIU)Target PopulationSection 2.2FunctionsPotentialExclusion CriteriaSection 2.4Intake,Triage andAdmissionTransitionof CareSection 5.6Section 5.1ReviewAssessmentSection 5.2Section 5.5Techniquesand therapiesSection 6PartnershipsSection 3NSW HealthSection 2.3Provisionof CareSection 5.3Differentsettings anddifferent waysSection 4OPMH – Key Features of the Model of CareCarePlanningSection 5.2StaffingSection 7PerformanceSection 83
IntroductionWhy develop a Model of Care for NSW OPMH Community Services? to guide and promote service improvement and consistent good practice in NSW OPMH communityservices, and to improve care for older people with mental illness.Who is the Model of Care for? OPMH community services throughout NSW, andBehavioural Assessment and Intervention Services (BASIS) teams where they still exist.Principles underlying the Model of CareThe MoC is guided by the principles of:recoveryconsumer-led care andpartnering with the consumer, carer(s), GP, and services/supports.It is evidence-based and aligns with key national and state standards and policies.The figure on page 5 depicts the role of OPMH community services from the consumer’s perspective.OPMH services are seen as one part of a complex system of care that supports a consumer’s recovery journey.The MoC recognises and supports this perspective.Overview of the MoCThere are seven key components in the MoC:1Philosophy of care, target population and functions2Partnerships3Working in different ways and in different settings4Key processes5Techniques and therapies6Staffing7PerformanceSee GL2017 003 for more information including the detailed ‘good practice features’ in each area of the MoC.4NSW HealthOPMH – Key Features of the Model of Care
SupportServicesPERSRELAT ONAION ContinuiANCO S ONN CIALECTEDEPERSON A LIIN GFUL LN E SSFHEASupportServicesngto be me with ameaningful & contributing lifeD PEREVSEL ONALOPMENTOCCUPATIONAINS rtServicesConsumerIntake,Triage andAdmissionGeneral PracticeCarer(s)Domains of a meaningful lifeTransitionof CareJourney of personal receoveryProvision of support(varying intensity)PartnershipsReviewOPMHCOMMUNITYSERVICES. partnering with the person,carer(s) and GP. focused on clinical recovery. facilitating key elementsof personal recoverySupport ServicesCare and supportProvision of care by OPMHCommunity Services (as one‘health’ support service)NSW HealthOPMH – Key Features of the Model of CareAssessmentCarePlanningProvisionof Care5
1. Philosophy of care, target populationand functionsRecovery-oriented, person-centred, biopsychosocial philosophy of care This philosophy guides how care is delivered in OPMH community services for all consumers, including:– involuntary consumers – focus on sustaining hope, promoting agency for recovery, supportingrelationships and redefining self– consumers with behavioural and psychological symptoms of dementia (BPSD) or co-existingconditions – support them to determine and address their own recovery goals (with carer and familyassistance as needed), which will be influenced by their own particular circumstances and the impact oftheir co-existing conditions. It should be reflected in organisational processes, including staff orientation, training and policies.Target population of OPMH community services & exclusion criteria Broadly, OPMH community services care for older people (generally 65 years and over) with mentalhealth problems (including those with and without dementia), and Aboriginal people aged 50 years or older with mental health problems, who themselves identify with theolder population and/or the specific needs of older consumers and want to be cared for in OPMHservices. An age limit should not be strictly applied. Flexibility and consumer choice is paramount.– Some consumers under 65 years with age-related problems causing functional disability may besuitable for OPMH services.– Some consumers aged 65 years or older may still be most appropriately cared for by adult mentalhealth services. OPMH community services will not generally provide services for older people with a primary diagnosis ofdrug and alcohol disorder or delirium. See NSW OPMH Service Plan 2017-2027 for more information.Facilitating timely access to care OPMH community services aim to accept any person referred to them for secondary triage and/or initialassessment following triage. Services should consider mechanisms to facilitate easy and timely access and re-access where that isnecessary.Caring for Aboriginal and CALD consumers (including refugees) Working in a culturally sensitive way is important. Consideration should be given to:– appropriate use of interpreters– partnerships and collaboration with Aboriginal Health Services and/or Aboriginal health/mental healthworkers, and transcultural mental health services, multicultural agencies, local non-health supportservices and/or bilingual workers– provision of culturally sensitive mental health information, and– tools to support appropriate assessment of CALD (e.g.1,2,3,4) and Aboriginal (e.g.5) people.6NSW HealthOPMH – Key Features of the Model of Care
Functions of OPMH community services All OPMH community services undertake specialist mental health assessment, care planning, short andlonger term clinical management (involving clinical care and coordination, treatment, clinical review andtransitions of care) and consumer advocacy, for older people with mental illness. Some services may also undertake specialist consultation and liaison, crisis care (intensive communitytreatment), and specific mental health promotion, illness prevention and early intervention activities.2. Partnerships Consumers, and carers where appropriate, should be recognised as partners in the management of allaspects of treatment, care and recovery planning. Partnerships and collaboration with a range of health, aged care and community services and providersare critical to meeting the complex needs of an older person with mental illness. OPMH community services should have a focus on strong relationships with, GPs and OPMH acuteinpatients units (where present) to promote integrated and continuous care. Each OPMH community service should prioritise relationships according to the needs of their localcommunity and local priorities, and develop strategies for improving/maintaining these relationships.3. Working in different settings and indifferent ways Consumers’ preferences regarding setting and modality of care – including face-to-face, telehealth and/orehealth – should be considered and supported where possible. Services should consider logistical arrangements such as access to transport and telehealth facilities andappropriate staff resourcing to support consumer preferences for receiving care. Telemedicine may be useful as an adjunct to face-to-face services, particularly in rural locations, but notas an alternative to these services. The digital mental health gateway – Head to Health – links Australians to online and phone mental healthservices, information and resources.64.Key processes In key clinical processes, OPMH community services should be recovery-focused and consumer-led.Services should particularly focus on:– promoting easy access to services and accepting all referrals for secondary triage and/or initialassessment. Consideration should be given to strengthening the interface with the NSW Mental HealthLine and GPs.– promoting wellness planning in care planning processes– supporting consumers to determine and address recovery goals in assessment and review processes– facilitating appropriate physical health assessment and care as per the Physical Health Care withinMental Health Services Policy Directive7 and Guidelines8– helping consumers gain access to a range of different services across the health and community caresectors, as required– maximising consumer choice and control, including when planning for transition of care/discharge.NSW HealthOPMH – Key Features of the Model of Care7
All clinicians must use mandated and state-support assessment tools. If other instruments arerecommended locally, these should supplement and not replace mandated tools, and only replace statesupported tools after LHD-level review. Specific engagement strategies, resources and assessment tools may be required to improve access andcare for priority population groups, including Aboriginal and CALD people. It is important to promote the role and target population of OPMH services to GPs, referral services,service partners and the community to help improve access to services.5. Techniques and therapies OPMH community services have a primary responsibility for facilitating clinical recovery, while supportingconsumers in other aspects of their recovery goals (e.g. by referrals to and partnerships with appropriatehealth and community care services and psychosocial supports). However, optimal ‘clinical’ interventions will involve a biopsychosocial approach, with the OPMH cliniciansupporting the consumer to manage their self-care, improve social and relationship skills and otheraspects of their life. Consumers should be able to access a range of evidence-based biopsychosocial therapies. To supportthis, each OPMH service should develop appropriate clinical governance processes, service deliveryarrangements and organisational supports, including:– guidance on the range of biopsychosocial therapies that may or may not be provided by OPMH staff,and– the process for accessing therapies that are not provided by staff including through inter-professionalpractice and utilisation of partnerships. Most therapies that are effective in younger people remain effective in later age. However specialisedknowledge or skills may be required to adapt them appropriately to an older person or someone withcognitive impairment. There are currently no national clinical standards on the clinical care of older people with mental illness.However, there are a number of resources available to guide OPMH clinicians. Examples of these areincluded in Appendix A. Older people with mental illness should have access to very specialised, non age-specific services (e.g.clozapine dosing, maintenance ECT and depot antipsychotic medications) and each OPMH communityservice will need to negotiate access to these services as appropriate. OPMH community services should have some capacity to provide clinical care for consumers withsubstance use issues, as outlined in the NSW Health Older People’s Drug and Alcohol Report.9 This mayinvolve provision of brief interventions and education where appropriate and/or close collaboration andjoint working with specialised drug and alcohol services.6. Staffing, leadership, clinical supervision& workforce development A strong service culture is vital. There should be clear operational and clinical leadership and governancearrangements that recognise and support the specialist nature of OPMH services. Multidisciplinary staffing is required in OPMH services. There should be a core staff of dedicated medicaland nursing staff and access to skills from other disciplines (including allied health). Staffing shouldsupport the provision of biopsychosocial therapies, either through direct provision or in partnership withother services/providers. OPMH clinicians will have core skills as outlined in the National Mental Health Core Capabilities10 anddiscipline-specific skills. They should have skills to work with older people with mental illness and a desireto further develop these specialist skills.8NSW HealthOPMH – Key Features of the Model of Care
The NSW Health Clinical Supervision Framework11 is a key resource. Specialist clinical supervision shouldfocus on clinical practice in the context of OPMH, with cross-discipline supervision supported whereappropriate. Staff must be enabled to access workforce development opportunities that further develop OPMHspecialised skills, competency and knowledge. There are a range of resources to help with this (e.g. 10,12,13,14).Other key documents may help promote cultural responsiveness (e.g.15,16). OPMH peer workers need to be treated as members of OPMH community teams and engaged in all teamactivities relevant to their roles. Services without peer workers may wish to consider how/if they canestablish peer work.7. Performance OPMH clinicians can help improve the quality and safety of OPMH services. Consider:– subscribing to the Australian Commission on Safety and Quality in Health Care On the Radarnewsletter which is a summary of some of the recent publications in the areas of safety and qualityin health care– joining an Agency for Clinical Innovation Clinical Network and/or Taskforce– actively participate in benchmarking, data review, accreditation and quality improvement processesand programs.NSW HealthOPMH – Key Features of the Model of Care9
Appendix A: Example resources toguide OPMH cliniciansScopeAustralian GuidanceAdaptation for AgeDepressionAmerican Psychological Association: Psychotherapyand Older Adults Resource GuideRANZCP: Clinical practice guideline: Mood disorderRANZCP: Position statement: Use ofantidepressants to treat depression in dementiaBeyond Blue: What works to promote emotionalwellbeing in older peopleAnxietyInternational GuidanceRANZCP: Clinical practice guideline: Panicdisorder, social anxiety disorder and generalisedanxiety disorderNICE: Depression in adults: recognition andmanagementNICE: Depression in adults with a chronic physicalhealth problem: recognition and managementNICE: Generalised anxiety disorder and panicdisorder in adults: managementNICE: Post traumatic stress disorder: managementBeyond Blue: What works to promote emotionalwellbeing in older peopleSchizophreniaRANZCP: Clinical practice guideline:Schizophrenia and related disordersNICE: Psychosis and schizophrenia in adults:prevention and managementBipolarRANZCP: Clinical practice guideline: Mood disorderNICE: Bipolar disorder: assessment and managementBPSD and dementiaNSW Health and RANZCP: Assessment andManagement of People with Behavioural andPsychological Symptoms of Dementia (BPSD): Ahandbook for NSW Health cliniciansIPA: The Complete Guides to Behavioural andPsychological Symptoms of Dementia (BPSD) – 3volumesNICE: Dementia pathwayNHMRC Cognitive Decline Partnership Centre:Clinical Practice Guidelines and Principles of Carefor People with DementiaAlzheimer’s Australia/DBMAS: Reducingbehaviours of concernDCRC-ABC: Behaviour Management: A Guide togood practice: Managing BPSDSuicideNSW Health: Clinical care of people who may besuicidalNICE: Self harm in over 80s: short-termmanagement and prevention of recurrenceRANZCP: Clinical practice guidelines for themanagement of adult deliberate self-harmNICE: Self harm in over 80s: long-term managementOccupationaltherapyOsborne Park Hospital, WA: Dementia: OsborneHospital Guide for Occupational Therapists inClinical PracticeNICE: Mental wellbeing in over 65s: occupationaltherapy and physical activity interventionsMental wellbeing inRACFsBeyond Blue: What works to promote emotionalwellbeing in older people: A guide for aged carestaff working in community or residential agedcare settingsNICE: Mental wellbeing in older people in carehomesPromoting mentalwellbeingEverymind: Prevention First: A prevention andpromotion framework for mental healthNICE: Older people: independence and mental wellbeingNSW Health: Wellbeing in Later Life: Your Guideto Programs and ActivitiesSocial interventionsUniversity of Toronto/Toronto Public Health, Canada:Best practice guidelines for mental healthpromotion programs: Older adults 55 NICE: Social care for older people with multiplelong-term conditions pathwayMental Health Foundation UK: An Evidence Reviewof the Impact of Participatory Arts on Older PeopleOptimisingconsumerexperience of serviceNICE: Service user experience in adult mentalhealth: improving the experience of care for peopleusing adult NHS mental health servicesDrug and AlcoholNICE: Alcohol-use disorders: diagnosis, assessmentand management of harmful drinking and alcoholdependenceNote: Every effort has been m
4 NSW Health OPMH – Key Features of the Model of Care Introduction Why develop a Model of Care for NSW OPMH Community Services? to guide and promote service improvement and consistent good practice in NSW OPMH community services, and to improve care for older people with mental illness. Who is the Model o
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