What are the evidence bases for developing models of rehabilitation for older people with mental illness in Australia?

OBJECTIVE: This paper updates clinicians and service leaders on evidence bases relevant to rehabilitation for older Australians with mental illness. METHODS: Narrative review of literature and relevant public domain data supported by reflections on NSW service development. RESULTS: There is a paucity of high-quality evidence regarding mental health rehabilitation in older people. Available evidence supports integrating lessons from physical healthcare with adaptations of 'adult' mental health rehabilitation. Adaptation is required to respond to the specific needs, strengths and service use of older people with mental illness. Challenges for older people include ageism, increased physical and cognitive comorbidities, lower access to mental health services and earlier residential aged care entry. Strengths of older people include an ongoing desire for recovery, ongoing developmental change and often closer connections with carers and GPs. Evidence is consistent with evaluation of relevant NSW service models and initiatives including the Pathways to Community Living Initiative. Integration of recovery-oriented practice and wellness models may provide a framework for future innovative inpatient and community-based models. CONCLUSIONS: There is sufficient evidence to guide development of models of rehabilitation with older people, but innovation and evaluation are essential if older people are to have equal opportunities in their recovery journeys.

Towards Zero Suicide: need and opportunities to improve implementation of clinical elements for older adults.

OBJECTIVE: The Zero Suicide (ZS) framework is increasingly used in Australia, but without published adaptations for older people, and limited access by older people when implemented. The aim of this paper is to inform Towards Zero Suicide (TZS) implementations to benefit older adults by considering the key differences in older adults at risk of suicide according to each clinical component of the ZS framework. CONCLUSION: TZS aspires to reduce deaths by suicide for people within healthcare by refocusing interventions on suicidality rather than diagnosis alone, emphasising evidence-based practices and cultural change. For TZS to be effective for older people, it is essential to ensure practices are based upon evidence relevant to older people and to ensure ageism is effectively counteracted. Older adults have distinct patterns of help seeking and service use, accompanied by differences in risk factors, presentations, and outcomes of suicidal behaviours. Ageism affects assessment, decision-making and actions to address self-harm and suicide for older people. Immediate and longer-term actions are essential to effectively implement TZS in this population.

Towards Zero Suicide for older adults: implications of healthcare service use for implementation.

OBJECTIVE: Implementing the Towards Zero Suicide (TZS) approach to suicide prevention in older adults requires evidence-based adaptation. This paper aims to highlight important differences and opportunities in healthcare service use by older adults relevant to implementation. CONCLUSION: The TZS approach may prevent suicide in older adults, but only if implementation aligns with systemic differences in healthcare utilisation by older people. Of greatest importance in older adults are (1) most mental healthcare is delivered outside of specialist mental health services; (2) physical conditions and disability are major modifiable contributors to suicide that must be addressed within TZS; and (3) older people have very low use of Medicare-funded psychological services. Primary healthcare providers, who may be seeing older people at risk of suicide, are often neither equipped to provide expert assessment and care planning for often complex needs, nor may see this as their role. However, they are essential in providing pathways to care, which may prevent suicide. Leaders must recognise TZS for older people will usually involve multiple transitions. This requires engagement of key services with clear roles, targeted training, rapid access to specialist older persons mental health support and development of a new TZS element: the navigator.

Implementing recovery-oriented practice in older people’s mental health services: the NSW experience.

Personal recovery is central to Australian mental health standards, but promoting recovery-oriented practice remains a wicked problem (ie complex, with definitions and appropriate interventions impacted upon by context and values), with limited evidence regarding effective implementation. This case study re-examines a statewide initiative to enhance recovery-oriented practice in older people's mental health services in New South Wales from the perspective of complex adaptive systems. The initiative consisted of three key strategies: (1) statewide collaborative leadership and practice resources; (2) locally determined and led improvement projects; and (3) evaluating, disseminating and sustaining initiative outcomes. Published outcomes of the initiative, related policy and benchmarking materials and author reflections are used to propose lessons for other services and policy makers. From a systems perspective, a relatively small investment from a state policy unit to enhance a facilitating environment resulted in the emergence of local leaders and voluntary participation of services within 80% of local health districts without funding incentives. Local leaders and activities informed statewide policies and models of care to sustain practice change. Limitations included variability in project scopes and the involvement of people with lived experience, as well as the level of refinement in change management approach. Self-audit and consumer-rated experience suggest resilience of practice and culture change. The outcomes are consistent with conceptualisations of mental health services being complex adaptive systems requiring distributive leadership. Established mechanisms encouraging statewide cooperation between clinicians, service managers and policy makers may have been significant facilitators of engagement in practice change. What is known about this topic? Recovery remains an important concept for older people with mental ill health, with implementation of recovery-oriented practice a wicked problem. What does this paper add? Central policy investment in a collaborative facilitatory environment can stimulate the emergence of local leadership and investment in actions to enhance recovery orientation. As predicted by complex adaptive systems theory, the impact of the leaders developed may be broader than the sum of individual project outcomes. What are the implications for practitioners? A start where you can message can engage and enable leaders in feasible and locally relevant changes consistent with a statewide strategy. This may be a feasible approach to improving recovery orientation in mental health care services for and beyond older people, with potential implications for addressing other wicked problems in health care.

Opinion: psychiatry formal education courses have been lost in transition.

OBJECTIVE: With reference to relevant literature, this article explores the impact of moving to a competency-based training programme upon psychiatry formal education courses (FECs). CONCLUSIONS: In the context of major changes in psychiatry training, FECs have lost clarity of role, alignment and governance. Strategic decisions made with key stakeholders are required to continue to train psychiatrists best able to meet future community needs.

Older people's mental health in rural areas: Converting policy into service development, service access and a sustainable workforce.

This paper describes the older people's mental health workforce development, policy development and implementation process and quantifies the rural service delivery and access impacts over a 15-year period in New South Wales. It highlights the factors that are considered to be critical to successful rural service development such as commitment to funding parity, investment in strong local service leadership, and development of innovative, locally adapted rural service models. Building on these foundations, the Older People's Mental Health Program in New South Wales was able to address key challenges relating to service access in rural health and develop new, sustainable specialist older people's mental health service networks. A sustained focus on policy and implementation which explicitly supports rural older people's mental health service enhancement, and development of evidence-based models of care, has significantly improved access to specialist mental health care for older people in rural areas. It has delivered 23 new rural older people's mental health community teams and a 440% increase in the number of people accessing these teams. It has also doubled the number of acute inpatient units and established new specialist mental health-residential aged care partnership services in rural New South Wales. It has resulted in increased access to services for the "older old," while not diminishing older people's rates of access to general adult mental health services. It has also supported innovative, sustainable rural service models such as "hub and spoke" models and step-up step-down inpatient services that build on existing health and hospital infrastructure and link geographically dispersed specialist clinicians and services together in rural service delivery.

Review and update of the Health of the Nation Outcome Scales for Elderly People (HoNOS65+).

Aims and methodThe Health of the Nation Outcome Scales for Elderly People (HoNOS65+) has been used widely for 20 years, but has not been updated to reflect contemporary clinical practice. The Royal College of Psychiatrists convened an advisory board, with expertise from the UK, Australia and New Zealand, to propose amendments. The aim was to improve rater experience when using the HoNOS65+ glossary by removing ambiguity and inconsistency, rather than a more radical revision. RESULTS: Views and experience from the countries involved were used to produce a series of amendments intended to improve intra- and interrater reliability and improve validity. This update will be called HoNOS Older Adults to reflect the changing nature of the population and services provided to meet their needs. These improvements are reported verbatim, together with the original HoNOS65+ to aid comparison.Clinical implicationsFormal examination of the psychometric properties of the revised measure is needed. However, clinician training will remain crucial.Declaration of interestNone.

Survey of aged psychiatry services' support of older Australians with very severe, persistent behavioural symptoms of dementia.

OBJECTIVE: To map the provision of community, acute, non-acute and residential care-based state-funded mental health services to older people with severe, persistent behavioural symptoms of dementia. METHODS: An electronic survey was completed in 2015 by senior representatives of aged persons' mental health services across Australia's six states. RESULTS: Jurisdictions varied widely in the number, geographic spread and make-up of aged persons' mental health community teams when adjusted for aged population; their number of acute and non-acute beds, and especially in the provision of specialist residential beds or partnerships with non-government providers. CONCLUSION: There is no nationally accepted pathway of care for this vulnerable group or understanding of what constitutes an adequate statewide mental health service.

The art and science of using routine outcome measurement in mental health benchmarking.

OBJECTIVE: To report and critique the application of routine outcome measurement data when benchmarking Australian mental health services. METHOD: The experience of the authors as participants and facilitators of benchmarking activities is augmented by a review of the literature regarding mental health benchmarking in Australia. RESULTS: Although the published literature is limited, in practice, routine outcome measures, in particular the Health of the National Outcomes Scales (HoNOS) family of measures, are used in a variety of benchmarking activities. Use in exploring similarities and differences in consumers between services and the outcomes of care are illustrated. This requires the rigour of science in data management and interpretation, supplemented by the art that comes from clinical experience, a desire to reflect on clinical practice and the flexibility to use incomplete data to explore clinical practice. CONCLUSIONS: Routine outcome measurement data can be used in a variety of ways to support mental health benchmarking. With the increasing sophistication of information development in mental health, the opportunity to become involved in benchmarking will continue to increase. The techniques used during benchmarking and the insights gathered may prove useful to support reflection on practice by psychiatrists and other senior mental health clinicians.

Reclaiming the best of the biopsychosocial model of mental health care and 'recovery' for older people through a 'person-centred' approach.

AIM: The 'biopsychosocial', 'person-centred care' (PCC) and 'recovery' models of care can be seen as distinct and competing paradigms. This paper proposes an integration of these valuable perspectives and suggestions for effective implementation in health services for the elderly. METHOD: An overview of PCC and recovery models, and their application for older people with mental health problems, is provided. Their overlap and contrast with the familiar 'biopsychosocial' model of mental health care is considered, together with obstacles to implementation. RESULTS: Utilisation of PCC and recovery concepts allow clinicians to avoid narrow application of the biopsychosocial approach and encourages clinicians to focus on the person's right to autonomy, their values and life goals. CONCLUSIONS: Service reform and development is required to embed these concepts into core clinical processes so as to improve outcomes and the quality of life for older people with mental health problems.

Expensive detour or a way forward? The experience of routine outcome measurement in an aged care psychiatry service.

OBJECTIVE: This paper describes and reflects upon the experience of a small, integrated aged care psychiatry service that has utilized the National Outcomes Casemix Collection (NOCC) routine outcome measurements within clinical practice, service management and evaluation. The goals of the NOCC initiative are reviewed in light of this experience. CONCLUSION: Routine outcome measurement has the potential to significantly improve aged care psychiatric service delivery. The service described has developed a model that the authors believe demonstrates the potential for routine outcome measures to improve the monitoring of patient progress, care planning, team communication, management and the understanding of service effectiveness - goals that are consistent with NOCC philosophy. However, this requires both ongoing development of infrastructure support and the willingness of clinicians to explore their utility.