Shortcomings of services for persons with severe and persistent mental health challenges: a qualitative study of service users and family carers.

Introduction: The opinions of service users and carers are crucial to identifying ways to innovate and implement system change. This study aims to explore the views and experiences of service users and carerson the services they have used for their mental health challenges and their suggestions for service reform. Methods: Twenty participants (15 carers and 5 service users) were interviewed for the study. Results: Eight categories emerged from the data. They were: Several gaps in the system, Barriers to accessing services, Services are not fit for purpose, Services operate in isolation, System is not person focused, Service users and carers are treated poorly, Services are overloaded and under resourced and Recommendations for service reform. Respondents reported that a persistent lack of funding and resources for mental health services was a main cause of these shortcomings. Respondents also noted that innovations were needed to re-orient services to enable continuity of care, and training of mental health professionals was needed for a better understanding of the needs of service users and their carers. Discussion: Additional research is needed with larger and more diverse samples to further explore these findings.

Mental health integrated care models in primary care and factors that contribute to their effective implementation: a scoping review.

BACKGROUND: In the state of Victoria, Australia, the 111-day lockdown due to the COVID-19 pandemic exacerbated the population's prevailing state of poor mental health. Of the 87% of Australians who visit their GP annually, 71% of health problems they discussed related to psychological issues. This review had two objectives: (1) To describe models of mental health integrated care within primary care settings that demonstrated improved mental health outcomes that were transferable to Australian settings, and (2) To outline the factors that contributed to the effective implementation of these models into routine practice. METHODS: A scoping review was undertaken to synthesise the evidence in order to inform practice, policymaking, and research. Data were obtained from PubMed, CINAHL and APA PsycINFO. RESULTS: Key elements of effective mental health integrated care models in primary care are: Co-location of mental health and substance abuse services in the primary care setting, presence of licensed mental health clinicians, a case management approach to patient care, ongoing depression monitoring for up to 24 months and other miscellaneous elements. Key factors that contributed to the effective implementation of mental health integrated care in routine practice are the willingness to accept and promote system change, integrated physical and mental clinical records, the presence of a care manager, adequate staff training, a healthy organisational culture, regular supervision and support, a standardised workflow plan and care pathways that included clear role boundaries and the use of outcome measures. The need to develop sustainable funding mechanisms has also been emphasized. CONCLUSION: Integrated mental health care models typically have a co-located mental health clinician who works closely with the GP and the rest of the primary care team. Implementing mental health integrated care models in Australia requires a 'whole of system' change. Lessons learned from the Mental Health Nurse Incentive Program could form the foundation on which this model is implemented in Australia.

Clinicians' and Users' Views and Experiences of a Tele-Mental Health Service Implemented Alongside the Public Mental Health System during the COVID-19 Pandemic.

A tele-mental health model called Head to Health was implemented in the state of Victoria, Australia to address the crisis caused by the COVID-19 pandemic. It was a free centralized intake service that adopted a targeted approach with several novel elements, such as stepped care and telehealth. This study examines the views and experiences of clinicians and service users of the tele-mental health service in the Gippsland region of Victoria during the COVID-19 pandemic. Data from clinicians were obtained via an online 10-item open-ended survey instrument and from service users through semi-structured interviews. Data were obtained from 66 participants, including 47 clinician surveys and 19 service user interviews. Six categories emerged from the data. They were: 'Conditions where use of tele-mental health is appropriate', 'Conditions where tele-mental health may not be useful', 'Advantages of tele-mental health', 'Challenges in using tele-mental health', 'Client outcomes with tele-mental health', and 'Recommendations for future use'. This is one of a few studies where clinicians' and service users' views and experiences have been explored together to provide a nuanced understanding of perspectives on the efficacy of tele-mental health when it was implemented alongside public mental health services.

Centralized Intake Models and Recommendations for Their Use in Non-Acute Mental Health Services: A Scoping Review.

Centralized intake [CI] or single-entry models are utilized in health systems to facilitate service access by reducing waiting times. This scoping review aims to consolidate the Literature on CI service models to identify their characteristics and rationales for their use, as well as contexts in which they are used and challenges and benefits in implementing them. The review also aims to offer some lessons learned from the Literature and to make recommendations for its implementation in non-acute mental health services. The findings show that CI is mostly considered when there is increased demand for services and clients are required to navigate multiple services that operate individually. Successful models have meaningfully engaged all stakeholders from the outset and the telephone is the most common mode of intake. Recommendations are made for planning and preparation, for elements of the model, and for setting up the service network. When successfully implemented, CI has been shown to improve access and increase demand for services. However, if CI is not supported by a network of service providers who offer care that is acceptable to clients, the purpose of its implementation could be lost.

Content analysis of nurses' reflections on medication errors in a regional hospital.

BACKGROUND: Medication errors [MEs] continue to be an area of concern both nationally and internationally. METHODS: Sixty-eight reflective summaries detailing reasons for medication errors completed by nurses at an Australian regional teaching hospital during a five-year period were analysed. RESULTS: Fifteen codes emerged from the data that aligned to three main categories of the Human Factors Framework. They were: Individual characteristics such as inexperience, stress and lack of knowledge (5 codes), Nature of the work such as prescription errors, time pressure, miscommunication, poor handover and documentation errors (9 codes) and Physical environment such as distractions (1 code). Individual characteristics were the most frequently reported (51.6%) reasons for the error. CONCLUSIONS: Provision of medicine information resources and management of nurses' workload as well as enhancing graduate nurse education with simulation of 'real life' clinical settings appear to be the main targets for intervention.

Dermatological presentations to a regional Victorian hospital emergency department: A 1-year audit.

OBJECTIVES: The objective of this study is to describe the epidemiological features of each presentation with a primary dermatological diagnosis to a regional emergency department (ED). DESIGN: 1-year retrospective audit. SETTING: Regional Victorian hospital emergency department. PARTICIPANTS: Any presentation to this regional emergency department with a dermatological condition from 1 January 2020 to 31 December 2020. MAIN OUTCOME MEASURES: Dermatology presentations to the ED in 2020 and the prevalence of the associated primary diagnosis. RESULTS: In total, 4.7% (n = 1873) of ED presentations had a primary dermatological diagnosis. Of these, 1484 were ≥18 years of age and 389 were ≤17 years of age. Cellulitis (26.1%, n = 388) was the most common primary diagnosis among presentations ≥18 years. Non-specific rash was the most common diagnosis (23.6%, n = 92) in presentations ≤17 years. Indigenous Australians ≥18 years were more likely to be in a younger age group (p < 0.01), and dermatitis/eczema presentations ≥18 years (n = 10) were the largest diagnostic group referred to a dermatologist. A total of 134 (7.1%) patients ≥18 years travelled more than 50 km to the ED. There were no dermatological emergencies identified. CONCLUSIONS: A high proportion of presentations to this regional ED with a dermatological diagnosis could be well managed by a dermatologist or general practitioner (GP) as an outpatient. The findings of this study inform the need for future rural public dermatology services. Options include teledermatology, or a public weekly or fortnightly rapid review dermatology clinic with a visiting dermatologist, in the absence of a dermatologist onsite.

Rural health service leaders co-design state-wide research addressing an emerging health issue: A case report.

AIMS: This commentary aims to describe a case of how meaningful co-design between rural health service leaders and a health service-embedded research unit can identify emerging research priorities and optimise translation. CONTEXT: The challenges facing rural health services are unique, and the important role of health service leaders in the research response is increasingly recognised. Poorly-designed research can contribute to research waste through reduced applicability of results to rural communities, and an opportunity exists to increase research co-designed with rural health services through the involvement of research users during study planning. APPROACH: In early 2020, leaders at a rural Victorian health service approached the embedded health service research unit to request research be conducted on an emerging issue: rural staff well-being in the face of the COVID-19 pandemic. This was based on their concern regarding the lack of available COVID-19-specific evidence to inform organisational policy. In collaboration with the rural health service executive, a translation-focused study of staff well-being with nine rural Victorian health services was developed. Key co-design activities of the project included involving research end-users as study investigators and conducting formal stakeholder engagement regarding study design and outcomes. CONCLUSION: Meaningful co-design of research with health services is a multifaceted process that can assist researchers and end-users alike in identifying and responding to emerging health issues. In the rural setting where there is a vital need for impactful health research, we recommend that researchers should consider employing co-design processes in order to minimise research waste and optimise the translatability of research findings.

Effectiveness of personal recovery facilitators in adults with schizophrenia and other psychoses: A systematic review of reviews and narrative synthesis.

This review aimed to examine the evidence base for the use of personal recovery facilitators [non-psychopharmacological approaches] for adults with a diagnosis of schizophrenia and other psychoses. A systematic review (umbrella review) was conducted of reviews published in English between January 2010 and February 2022, which examined the effectiveness of personal recovery facilitators to support aspects of personal recovery as defined by the CHIME framework (connectedness, hope and optimism, identity, meaning and purpose, and empowerment). Twenty-one systematic reviews on thirteen different types of personal recovery facilitators [PRFs] were included in this umbrella review. Only one review sought to directly measure personal recovery processes according to the CHIME framework. Outcome measures mostly aligned with the processes of hope (21 reviews) and connectedness (19 reviews). Those related to empowerment (2 reviews), identity (5 reviews) and meaning and purpose (1 review) were less frequently the focus of PRFs. Yoga and music therapy showed the most promise as PRFs. Vocational treatments and integrated supported employment show good potential as personal recovery facilitators. However, together with narrative photovoice, art making and exhibition, they require further robust research to fully examine their impact. Personal recovery is only beginning to be considered as an intended outcome of interventions for persons with schizophrenia and other psychoses. This may be due in part to the continued predominance of the biomedical model approach to recovery within statutory services. Future evaluations of PRFs should include outcome measures that directly assess personal recovery according to the CHIME framework or other measures developed in consultation with recipients of these approaches. Review registration number and date: PROSPERO 2020 CRD42020215471: 10/11/20.

Strategies to Facilitate Mental Healthcare Access in Marginalised Local Communities: Case Studies from India and Australia.

BACKGROUND: Mental disorders are amongst the highest contributors to the Global Burden of Disease. However, despite the universal reach of these disorders, there are vast disparities in the provision of mental health services both between and within nations. Marginalised groups such as rural communities, ethnic minorities, refugees and indigenous peoples are known to be at higher risk of experiencing mental disorders but do not receive adequate care for it. AIMS OF THE STUDY: The purpose of this paper is to describe lessons learnt in designing and setting up mental health services for two marginalised communities - one in rural India and the other in an Aboriginal community in South Eastern Australia. METHODS: Two case studies of setting up a mental health service are described and compared to identify key elements to consider when developing services for hard to reach and marginalised communities. RESULTS: Four key elements were identified. They are: (i) Overcoming issues related to mental health literacy (Recognising mental illness and knowing where treatment is available) (ii) De-stigmatising the service (iii) Rendering the service culturally safe and (iv) Ensuring financial sustainability. DISCUSSION: Marginalised communities commonly experience an unmet need for mental health services. This includes indigenous peoples around the world who continue to experience various forms of disadvantage. As a result, traditional mainstream services are needing to rethink the way they do business so as not to exclude those who need them the most. The involvement of suitable link persons can play a crucial role in addressing the unmet need for mental health services in these communities. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The increasing movement of population groups across geographical boundaries including refugees has resulted in major changes in the cultural make- up of populations over a short period of time. The elements generated from these models can be utilised in expanding mental health service provision to include such communities. IMPLICATIONS FOR HEALTH POLICIES: Clear policies need to be developed to address the unmet need of hard to reach and marginalised communities for appropriate and accessible mental health services. This paper offers some direction for policy development in this space. IMPLICATIONS FOR FURTHER RESEARCH: Further research and trials of service models to address the unmet need for mental health services among marginalised communities can be informed by the lessons learnt from these experiences.

Factors affecting learning during internship: A qualitative study of junior doctors.

BACKGROUND AND OBJECTIVES: Internship is a crucial period of learning for medical graduates. The aim of this study was to ascertain what interns learned during internship, who they learned from and the type of environments that influenced their learning. METHOD: This qualitative study was conducted within the constructivist paradigm of Vygotsky's sociocultural theory of learning. RESULTS: Interns mostly learned what they were expected to learn. They built on their existing knowledge with help from a more knowledgeable other and in an environment that was conducive to learning except when they needed to manage complex situations on their own with no previous experience or training. Learning was influenced by factors related to the workplace, supervisor or senior doctor and learner. DISCUSSION: The learning environment is inextricably related to the professional behaviour of clinical teachers and supervisors. A safe and supportive learning environment is necessary for optimal learning outcomes during internship.

Care coordination as a collaborative element of recovery oriented services for persons with severe mental illness.

OBJECTIVE: To propose a model where care coordination can form part of recovery oriented care when it is included as a collaborative element of services for persons with severe mental illness. CONCLUSION: A recovery-oriented service requires more than clinical interventions. It also needs to address social determinants and be individualised or person centred. Multiple health and community services need to be involved. A care coordination model is capable of addressing multiple needs. It gives the client the first and foremost voice. It facilitates intersectoral collaboration, reduces the burden on clinical mental health services and is supported by mental health and community service personnel.

Hospital medication errors: a cross-sectional study.

BACKGROUND: Medication errors (MEs) are among the most common types of incidents reported in Australian and international hospitals. There is no uniform method of reporting and reducing these errors. This study aims to identify the incidence, time trends, types and factors associated with MEs in a large regional hospital in Australia. METHODS: A 5-year cross-sectional study. RESULTS: The incidence of MEs was 1.05 per 100 admitted patients. The highest frequency of errors was observed during the colder months of May-August. When distributed by day of the week, Mondays and Tuesdays had the highest frequency of errors. When distributed by hour of the day, time intervals from 7 am to 8 am and from 7 pm to 8 pm showed a sharp increase in the frequency of errors. One thousand and eighty-eight (57.8%) MEs belonged to incidence severity rating (ISR) level 4 and 787 (41.8%) belonged to ISR level 3. There were six incidents of ISR level 2 and only one incident of ISR level 1 reported during the five-year period 2014-2018. Administration-only errors were the most common accounting for 1070 (56.8%) followed by prescribing-only errors (433, 23%). High-risk medications were associated with half the number of errors, the most common of which were narcotics (17.9%) and antimicrobials (13.2%). CONCLUSIONS: MEs continue to be a problem faced by international hospitals. Inexperience of health professionals and nurse-patient ratios might be the fundamental challenges to overcome. Specific training of junior staff in prescribing and administering medication and nurse workload management could be possible solutions to reducing MEs in hospitals.

Coping styles and mental health in response to societal changes during the COVID-19 pandemic.

BACKGROUND: Psychosocial responses to infectious disease outbreaks have the potential to inflict acute and longstanding mental health consequences. Early research across the globe has found wide ranging psychological responses to the current COVID-19 pandemic. Understanding how different coping styles can be effective in mitigating mental ill health would enable better tailored psychological support. AIMS: The aim of this study was to gain an understanding of psychosocial responses to the COVID-19 pandemic, including depression, anxiety and distress, as well as effective coping styles in an Australian sample. METHOD: A sample of 1,495 adults, residing in Australia between April 3rd and May 3rd 2020, completed an online survey which measured psychological distress (Impact of Events Scale-Revised), depression, anxiety, stress (DASS-21), as well as coping strategies (Brief COPE). RESULTS: 47% of the respondents were experiencing some degree of psychological distress. Females experienced higher levels of depression, anxiety and stress than males. Coping strategies associated with better mental health were positive reframing, acceptance and humour. Conversely, self-blame, venting, behavioural disengagement and self-distraction were associated with poorer mental health. CONCLUSION: Rates of psychological symptoms amongst the Australian population are similar to those reported in other countries. Findings add to the growing literature demonstrating a gender disparity in the mental health impacts of COVID-19. Positive emotion focused coping strategies may be effective for reducing psychological symptoms. Understanding psychosocial responses including beneficial coping strategies are crucial to manage the current COVID-19 situation optimally, as well as to develop mental health response plans for future pandemics.

PERSPECTIVES: Recovery Oriented Services for Persons with Severe Mental Illness Can Focus on Meeting Needs Through Care Coordination.

BACKGROUND: The approach to care for persons with an acute illness is different from that for a person with a chronic disease. Whilst the goal of treatment for an acute illness is to cure the disease, a chronic condition has no cure as such, and hence management requires a team approach that is aimed at achieving goals that are jointly set by service users and providers. Severe and persistent mental illness (SPMI) is a chronic disease. However, in many mental health services, the approach to care for persons with SPMI is similar to those who have an acute mental illness. AIM: The aims of this paper are twofold: (i) to make an argument for recovery oriented services to focus on meeting clients' needs rather than on symptom reduction, (ii) to propose a model of service provision where clinical mental health services form a part rather than the mainstay of care for people with SPMI. RESULTS: Using examples from Australia's Partner's in Recovery initiative and other recovery literature, we start by describing how SPMI should be treated as a chronic disease that focuses on recovery. We then highlight how mental health services continue to monitor outcomes based on clinical rather than personal recovery. Next, we diagrammatically illustrate how needs can be aligned with the recovery process and illustrate how care coordination can be the hub of service delivery in a hub and spoke model. We conclude with comments on workforce requirements and costs of a needs-based recovery oriented service. DISCUSSION: In a needs based model, the role of the specialist mental health service will move from being at the centre of care to being one of the components of care and the role of the care coordinator will become central. Although, there are as yet no randomised controlled trials to show that meeting needs of persons with SPMI will significantly contribute to their recovery, preliminary studies show that it is possible. IMPLICATIONS FOR HEALTHCARE PROVISION AND USE: The role of the care coordinator becomes the hub of service provision collaborating with agencies such as family practices, specialist mental health services, legal, housing, employment, education, and community services. IMPLICATIONS FOR HEALTH POLICIES: A shift from the current model of care to a needs based approach requires a revolutionary change in the way we do business and will have to be the largest shake up of the mental health service system since deinstitutionalisation. IMPLICATIONS FOR FURTHER RESEARCH: It is a long journey from the status quo to a needs based approach. The first step would be to gather more evidence on the usefulness of addressing people's needs in achieving recovery.

Job satisfaction of rural medical interns: A qualitative study.

OBJECTIVE: To study reasons for job satisfaction and dissatisfaction among interns. DESIGN: Using a qualitative methodology, one-to-one interviews were conducted with interns. SETTING: The study was based at a Victorian Rural Intern Training program. PARTICIPANTS: Twelve interns from the program were interviewed during their final rotation. MAIN OUTCOME MEASURES: Reasons for job satisfaction and dissatisfaction among rural interns. RESULTS: Reasons for job satisfaction included feeling supported in the workplace as well as getting quality supervision, teaching and clinical exposure. Reasons for job dissatisfaction included poor access to administration, unduly stressful working situations, lack of support for mental health and well-being, and poorly organised teaching sessions. CONCLUSION: The internship experience, together with the people they are influenced by, can determine a doctor's future career pathway. It is therefore vital for internship coordinators and hospital managers to facilitate a positive internship experience. The findings have implications for human resource management policy and practice in rural hospitals.

Care Coordination Can Reduce Unmet Needs of Persons With Severe and Persistent Mental Illness.

Introduction: Persons with severe and persistent mental illness (SPMI) have multiple and complex needs, many of which are not health related. Mental health services are unable to address these needs without collaboration with other agencies. In the absence of this collaboration, persons with SPMI often fall through the system cracks and are unlikely to experience recovery. Furthermore, previous studies have shown that unmet accommodation needs are associated with unmet needs in other areas. This study aimed to ascertain whether a care coordination model adopted in Australia's Partners in Recovery [PIR] initiative was able to reduce unmet needs in such persons and also if meeting accommodation needs were associated with meeting other needs. Methods: This was a longitudinal study where met and unmet needs of clients measured using the Camberwell Assessment of Needs Short Appraisal Schedule (CANSAS) were compared at enrolment and exit from the PIR initiative. Logistic regression was used to examine the association between change in accommodation needs and change in other CANSAS variables. Results: In total, 337 clients (66% of 508 clients) had both baseline and follow-up data and were seen within the time frame of 14 to 101 weeks. At baseline, the most frequently reported unmet needs were psychological distress, daytime activity, and company (89%, 72%, and 67%, respectively). At follow-up, these had decreased to 27%, 22%, and 22%, respectively. The proportions of clients with an unmet need at baseline who subsequently progressed to having that need met at follow-up ranged between 62% and over 90%. Change in accommodation needs from unmet to met was associated with changes in monetary needs and needs related to childcare, food, safety to self, education, and access to other services, with the greatest change seen for monetary needs (adjusted OR 2.87, 95% CI 1.76, 4.69). Conclusions: Reducing needs of persons with SPMI is the starting point of recovery and is a good indicator of psychiatric care. Care coordination is a useful way to address multiple and complex needs of persons with SPMI. While addressing needs, priority must be given to meeting accommodation needs.

Unmet needs of persons with a severe and persistent mental illness and their relationship to unmet accommodation needs.

This is a cross-sectional study of unmet needs of persons enrolled in Australia's Partners in Recovery (PIR) initiative. It aimed to explore the unmet needs reported by persons with a severe and persistent mental illness (SPMI) and to examine the associations between unmet accommodation needs and other unmet needs. The study was undertaken in the Gippsland region of Victoria from February to May 2015. Data were collected from the administrative database for the PIR initiative in Gippsland, which was held by the Gippsland Primary Health Network. Data on unmet needs, as measured by the Camberwell Assessment of Needs Short Appraisal Schedule, were analysed using proportions and logistic regression. Psychological distress, daytime activities, company/someone to spend time with and employment and volunteering were the most commonly reported unmet needs. Participants with unmet accommodation needs were less likely to receive information on their condition or access other services. They also had unmet needs relating to food, money, transport, childcare, looking after home, physical health, psychological distress and self-care. Supported accommodation may not be enough for persons with SPMI who have poor functioning skills and are incapable of looking after themselves. Services such as Housing First that have shown promising results need to be part of a comprehensive strategy to care for persons with severe and enduring mental illness.

Profile of transcultural patients in a regional Child and Adolescent Mental Health Service in Gippsland, Australia: The need for a multidimensional understanding of the complexities.

BACKGROUND: Several childhood stressors related to immigration have been documented, and it is important for clinicians to understand and address the various factors that may lead to or act as maintaining factors of mental disorders in children and adolescents. AIMS: To describe the cultural profile of transcultural patients presenting to a Child and Adolescent Mental Health Service (CAMHS) in regional Victoria and identify the most common disorders and psychosocial stressors they presented with. METHOD: Descriptive analysis was applied to 101 case records of patients with a transcultural background who attended the CAMHS of Latrobe Regional Hospital in Gippsland Victoria from 2013 to 2017. The Adverse Childhood Experience questionnaire was retrospectively applied to capture psychosocial stressors such as 'bullying', 'racism' and 'family conflict', sexual abuse, physical violence, parents with mental illness and parental substance use. RESULTS: Almost 60% of patients were male and over 46% Aboriginal. Those from a non-Aboriginal background belonged to 19 different cultural entities, the most common of which was a mixed Asian and European heritage. The most common diagnoses were disruptive mood dysregulation disorder (38.6%), attention-deficit hyperactivity disorder (32.7%) and developmental trauma disorder (26.7%). The most common psychosocial stressors were conflict and death in the family (44.6%), domestic violence (41.6%) and emotional abuse (34.7%). 'Parent in jail' and 'domestic violence' were associated with having an Aboriginal background ( p < .005). 'Cultural differences with parent' was associated with a non-Aboriginal background ( p < .005). CONCLUSION: This study provides a snapshot of challenges faced by children from different cultural backgrounds while adjusting in a rural area in Australia. A broad-based formulation and cultural awareness by clinicians can enable a better understanding of the complexities, guide management plans and inform public health policies for primary prevention and early intervention.

Concepts, Practices and Advantages of Spirituality Among People with a Chronic Mental Illness in Melbourne.

There is a relative paucity of literature in the field of spirituality among people who have a lived experience of severe mental illness from Australia. Sixteen individuals with a severe mental illness were interviewed on their experiences of spirituality. The three themes that emerged from the data were concepts of spirituality, benefits of intentional spiritual practices and perceived spiritual benefits of recreational pursuits and physical activity. This paper adds to the relatively sparse literature on spirituality among persons with a mental illness in Australia.