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MENTAL HEALTH STEPPED CARE MODEL South Eastern Melbourne Primary Health

Network (SEMPHN)

December 2016

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TABLE OF CONTENTS 1. Introduction ........................................................................................................................................ 5

1.1. What is the stepped care model? .................................................................................................... 5

1.2. Why has the stepped care model been developed? ..................................................................... 5

1.3. What is the scope of the stepped care model? ............................................................................ 6

1.4. How will it be used? .......................................................................................................................... 6

1.5. How was it developed? ...................................................................................................................... 7

2. The policy environment .................................................................................................................... 8

2.1. PHN commissioning ............................................................................................................................ 8

2.2. Mental health policy .......................................................................................................................... 8

2.3. Broader policy links ......................................................................................................................... 10

3. Regional profile ................................................................................................................................ 11

4. The stepped care model ................................................................................................................. 13

4.1. Design principles .............................................................................................................................. 13

4.2. Model overview ................................................................................................................................ 15

4.3. Service access and coordination ................................................................................................... 18

5. Operationalising the model ............................................................................................................ 20

5.1. Governance ....................................................................................................................................... 20

5.2. Implementation approach .............................................................................................................. 20

5.3. Program transition ........................................................................................................................... 21

6. Telling the story ............................................................................................................................... 22

6.1. Introduction ...................................................................................................................................... 22

6.2. Measuring outcomes ........................................................................................................................ 22

6.3. Reporting on performance ............................................................................................................. 22

7. Service elements .............................................................................................................................. 25

Appendix A References

FIGURES:

Figure 1 – Stepped care model .............................................................................. 16

Figure 2 – Governance arrangements ....................................................................... 20

Figure 3 – Implementation of the Stepped care model .................................................. 21

TABLES:

Table 1 – Core design principles ............................................................................ 13

Table 2 – Stepped care model outcomes framework ..................................................... 23

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GLOSSARY

Term Meaning

ATAPS Access to Allied Psychological Services

CALD Culturally and Linguistically Diverse

Consumer Consumers are those who access or who could potentially access mental

health services.

Gatekeeper A person who holds an influential position in an organisation or community

who coordinates the actions of others. This could be an informal local

opinion leader or a specially designated person, such as a primary-care

provider, who coordinates patient care and provides referrals to specialists,

and other medical services.

LGBTI Lesbian, Gay, Bisexual, Transgender and Intersex

LHN Local Hospital Network

MBS Medicare Benefits Scheme

MHNIP Mental Health Nurse Incentive Program

Natural supports People who have a support role for someone living with a mental health

difficulty. They may be a family member, friend, carer or have another

close relationship with the person.

PBS Pharmaceutical Benefits Schedule

PHN Primary Health Network

Self-harm Deliberate damage of body tissue, often in response to psychosocial

distress, without the intent to die. Sometimes called self-injury, self-

inflicted injuries, or non-suicidal self-harm/injury.

SEMPHN South Eastern Melbourne Primary Health Network

SEWB Social and Emotional Wellbeing

Severe and complex

mental illness

Like other health conditions, mental illness impacts at different levels of

severity, ranging from mild to severe. Clinically, severity is judged

according to the type of disorder the person has (diagnosis), the intensity of

the symptoms they are experiencing, the length of time they have

experienced those symptoms (duration) and the degree of disablement that

is caused to social, personal, family and occupational functioning

(disability). Some diagnoses, particularly schizophrenia and other

psychoses, are usually assigned to the severe category automatically, but all

disorders can have severe impact on some people.

An estimated 3.1% of the population have severe disorders, equivalent to

690,000 people. About one third of the severe group have a psychotic

illness, primarily schizophrenia or bipolar disorder. The largest group

(approximately 40%) is made of people with severely disabling forms of

anxiety disorders and depression.

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For the purpose of this document, severe and complex mental illness refers

to individuals with clinically severe mental illness as well as complex

multiagency needs, often both clinical and non-clinical, which may be or an

episodic or persistent nature.

Support

Treatment Clinical services received by a consumer

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1. Introduction

This document sets out a stepped care model for primary mental health services in the South

Eastern Melbourne region, intended to guide stakeholders in regional service planning and

development.

1.1. What is the stepped care model?

The stepped care model describes a continuum of key service elements that are required to

most efficiently provide needs-based support to people with (or at risk of) mental illness. It is

based on six design principles, which seek to shape a regional mental health system that is:

1. Person-centred: The model is person centred, mindful of natural supports, and recovery

orientated, and delivers a consistent experience no matter the entry point or pathway

through the system

2. Effective: The overall model and the service elements within it are supported by the

existing evidence base for approaches that work

3. Flexible: The model provides for a spectrum of service elements from least to most

intensive, in a range of modalities, times and places

4. Efficient: The model seeks to deliver access to the lowest cost service that will meet

each individual’s need

5. Timely: The model facilitates timely access to services both over the life course and

within an episode of illness

6. Coordinated: The model enables and supports coordination and integration of mental

health and other services in the region

The services that fall within the scope of the model are defined by the Australian Government’s

guidance on developing stepped care approaches in mental health (Department of Health,

2016g), as well as specific guidance relating to different service types (Department of Health,

2016a, 2016b, 2016c, 2016d, 2016e, 2016f, 2016h).

1.2. Why has the stepped care model been developed?

The stepped care model reflects SEMPHN’s intentions for strengthened primary mental health

services in the region, and provides a clear basis for future work planning, including

commissioning services.

Primary Health Networks (PHNs) have been established with the key objectives of increasing the

efficiency and effectiveness of medical services for patients, particularly those at risk of poor

health outcomes, and improving coordination of care to ensure patients receive the right care in

the right place at the right time.

A priority area for PHNs is primary mental health care. PHNs have regional responsibility for

commissioning approaches to service planning and development.

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1.3. What is the scope of the stepped care model?

PHNs have been funded to undertake comprehensive regional mental health planning and

identify primary mental health service gaps within a stepped care approach, and to commission

primary clinical mental health services.

Figure 1 – The stepped care model in context

While the stepped care model is designed to intersect and provide linkages, the following areas

are out of scope for the stepped care model:

psychosocial support services for consumers and natural supports

acute secondary and tertiary mental health services

severe and persistent care packages delivered under the NDIS

services outside of the SEMPHN catchment

services funded through private health insurers.

1.4. How will it be used?

The services and programs (‘service elements’) described within the model are the building

blocks for an effective primary mental health system. The model will directly inform how

SEMPHN implements its role in collaboration with consumers, natural supports, providers and

sector stakeholders to deliver on six priority areas of focus (Department of Health, 2016g):

1. appropriately support people with or at risk of mild mental illness through development

and/or commissioning of low intensity mental health services

2. support region-specific, cross sectoral approaches for children and young people with, or at

risk of mental illness, including those with severe mental illness being managed in primary

care

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3. address service gaps in the provision of psychological therapies for people in rural areas and

other under-serviced and/or hard to reach populations

4. commission primary mental health care services for people with severe mental illness being

managed in primary care, including clinical care coordination for people with severe and

complex mental illness

5. encourage and promote a regional approach to suicide prevention

6. enhance and better integrate Aboriginal and Torres Strait Islander mental health services at

a local level.

The model also emphasises intended outcomes for consumers and for the system overall. It

provides guidance on how progress towards these can be measured.

1.5. How was it developed?

The stepped care model represents a key output to an extensive process led by SEMPHN. Sector

wide consultations with consumers, natural supports , service providers and sector stakeholders

commenced as part of needs assessment and planning activity, and culminated in a workshop in

November 2016 at which the model was ‘road tested’ with key sector representatives. A

consumer and natural supports panel was convened to provide direct input to its development,

and a ‘peer review’ panel of experts reviewed the draft model.

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2. The policy environment

The stepped care model outlined in this document sits within the context of mental health

policy developments at the state and federal levels. This section outlines the policy context,

identifying the key policies which have informed the development of the stepped care model.

2.1. PHN commissioning

A key role for PHNs is to lead mental health and suicide prevention planning and integration at a

regional level in partnership with Local Hospital Networks (LHNs) and other key regional

stakeholders, consistent with the Government Response to the Review of Mental Health

Programmes and Services. All PHNs have key deliverables associated with this function in the

2017 financial year, including Mental Health and Suicide Prevention Needs Assessment (building

on initial assessments in 2016), and Mental Health Activity Workplans (Department of Health,

2016i).

Primary Health Networks are also expected to deliver Regional Mental Health and Suicide

Prevention Plans in 2017. There is a strong emphasis from government on the evidence-based

and regionally collaborative nature of these plans, and that they should be comprehensive in

that they are to address the full range of mental health services (with the apparent exception of

inpatient services). A key outcome expected of the plans is that they will also guide the efficient

commissioning and targeting of services by PHNs.

The focus of commissioning models is to be on strategically assessing needs and priorities and

shaping the local service system in response. This requires a systemic focus that extends beyond

narrow procurement of individual, siloed services.

The Commonwealth Government outlines a stepped care model as an approach with a “hierarchy

of interventions, from the least to the most intensive, matched to the individual’s needs”

(Department of Health, 2016g). The model is based on the approach outlined by the Australian

Government Response to Contributing Lives, Thriving Communities – Review of Mental Health

Programmes and Services (Department of Health, 2015). The Commonwealth Government

expects SEMPHN to commission mental health services for its catchment on the basis of the

model.

2.2. Mental health policy

Mental health policy frameworks exist at both the state and national level, influencing SEMPHN’s

work in the south-eastern Melbourne catchment. The main policy frameworks of relevance to

SEMPHN are:

the Victorian 10-Year Mental Health Plan (Department of Health and Human Services, 2015)

the Fifth National Mental Health Plan (currently in draft form under consultation).

The Victorian 10-Year Mental Health Plan was launched in 2015 and has four key focus areas:

improving the mental health and wellbeing of all Victorians

promoting mental health for all ages and stages of life

supporting Victorians with mental illness to live fulfilling lives of their choosing, with or

without symptoms of mental illness

achieving an accessible, flexible and responsive mental health service system and workforce.

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Additionally, the Fifth National Mental Health Plan is currently in draft and identifies the

following seven priority areas:

integrated regional planning and service delivery

coordinated treatment and supports for people with severe and complex mental illness

suicide prevention

Aboriginal and Torres Strait Islander mental health and suicide prevention

physical health of people living with mental health issues

stigma and discrimination reduction

safety and quality in mental health care.

These plans, and a number of other policy documents (see Annotated Bibliography) identify a

number of themes for the development of a mental health system that promotes the health,

wellbeing and recovery of people with mental illness.

The primary goal of the mental health system is improved outcomes for people with mental

illness, notably reduced rates of mental illness and suicide. As well as applying to all Australians

at a population level, there are specific target groups that experience high rates of mental ill-

health which needs to be addressed, including Aboriginal and Torres Strait Islander people,

LGBTI people and people with a culturally and linguistically diverse (CALD) background.

Part of the challenge of developing an effective mental health system is care coordination, both

within the system and holistically across the dimensions of people’s experiences. This means

coordination between services to ensure appropriate referrals are made. Additionally, it requires

mental health services to work with other community and social services to support a

consumer’s mental health, including education, housing, justice and family violence services.

In addition to improving the coordination of the system, there is a focus on improving the quality

and equity of services. Services and their staff should treat consumers with respect. People

should be able to access adequate services, regardless of their financial situation or location.

Where possible, consumers should have choice and control over the services that they access.

Alongside the emphasis on improving the quality and accessibility of services, reducing the

stigma and discrimination that people with mental illness face would improve their mental

health and wellbeing. Policy frameworks at the state and federal level emphasise the

importance of increasing action and education to reduce stigma, in the community and among

the health workforce.

In addition to the directions provided at the strategic level, services providing mental health

services are subject to the National Standards for Mental Health Services (Commonwealth of

Australia, 2010). These Standards outline a number of principles for the delivery of equitable,

quality mental health care, which inform the key performance indicators for health services.

NMHS: key principles for mental health service delivery

Effectiveness

Appropriateness

Efficiency

Accessibility

Continuity

Responsiveness

Capability

Safety

Sustainability

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2.3. Broader policy links

Mental health service delivery is complex, and intersects with a number of other health and

social policy areas.

The National Disability Insurance Scheme (NDIS) will have a significant impact on the provision of

mental health services in the community for consumers experiencing ‘complex and persistent’

psychosocial disability associated with mental illness (National Disability Insurance Agency,

2015). There are current concerns in the sector about the extent to which the NDIS can fully

cover the number of consumers who experience severe and complex mental illness.

In addition to mental health services, PHNs are also responsible for commissioning some drug

and alcohol treatment services. PHNs aim to reduce the harms associated with drugs and

alcohol, with a specific focus on methamphetamine use and supporting Indigenous services.

Given the high prevalence of dual diagnosis mental illness and substance misuse, it is important

to acknowledge the potential interaction of services, while noting the separation of funding and

commissioning arrangements.

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3. Regional profile

.

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4. The stepped care model

4.1. Design principles

The core principles informing the stepped care model are set out in Table 1, along with high

level outcomes that result from implementing these principles. These align to the

Commonwealth’s guidance for PHNs (Department of Health, 2016i, 2016j), and are informed by

consultations completed by SEMPHN with consumers, natural supports and service providers in

the region.

Table 1 – Core design principles

Design principle Long term outcomes from design implementation

Person-centred: The model is

person centred, mindful of

natural supports, and recovery

orientated, and delivers a

consistent experience no matter

the entry point or pathway

through the system

Consumers and those supporting them have a positive

experience when accessing support, care and treatment

Consumers experiencing social disadvantage access care on

an equitable basis

Consumers access services that are culturally safe and age-

appropriate

Consumers have choice and control over their mental health

service access as far as is reasonable

Effective: The overall model and

the service elements within it are

supported by the existing

evidence base for approaches that

work

Consumers experience improved mental health and

wellbeing outcomes

Rates of self-harm and suicide in at-risk groups are reduced

Flexible: The model provides for

a spectrum of service elements

from least to most intensive, in a

range of modalities, times and

places

Consumers access appropriate mental health care in

modalities aligned to their individual needs

Consumers access flexible services at times and places that

meet their needs

Efficient: The model seeks to

deliver access to the lowest cost

service that will meet an

individual’s need

Resources available to the system are deployed sustainably

and efficiently

Services are available consistently and equitably across the

region

Timely: The model facilitates

timely access to services both

over the life course and within an

episode of illness

Downstream costs of care decrease through earlier

intervention

Consumers access needs-appropriate mental health care in a

timely way

Coordinated: The model enables

and supports coordination and

integration of mental health and

other services in the region

Consumers with mental illness experience improvement in

cultural, physical and social outcomes

Consumers experience well-coordinated services as they

move through the stepped care model

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Service providers and clinicians experience a well-

coordinated system

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4.2. Model overview

A stepped care model has four core elements (Department of Health, 2016g):

1. stratification of the population into different ‘needs groups’

2. defining differentiated interventions for each group – this is necessary because not all needs

require formal intervention

3. a comprehensive ‘menu’ of evidence based services required to respond to the spectrum of

need

4. matching service types to the treatment needs of each needs group.

The stepped care model shown in Figure 2 stratifies the population into five groups, ranging

from whole of population needs for mental health promotion and prevention, through to those

with severe, persistent and complex conditions. It also clusters service types by the demographic

segment that they serve. The service groupings are:

General adult services, including services for older adults

Child and youth specific services

Services for socially disadvantaged groups, including (but not limited to), culturally and

linguistically diverse (CALD) people and new migrants, people experiencing homelessness,

and LGBTI people

Aboriginal and Torres Strait Islander services

The groupings are not mutually exclusive. Some consumers fall into all four groups, and most

service providers operate across more than one service grouping.

Within each service grouping, ‘service elements’ are described. Service elements are high-level

descriptions of the evidence-based service or programs that collectively make up the range of

interventions available to consumers within the system.

Service elements are each described in more detail within section 5, with the exception of

greyed out elements. The latter fall outside the scope of the model, but are key system

components that provide important context within the diagram. For clarification, not all of the

service elements will be funded by SEMPHN and the distribution of current funds will be directed

to support future commissioned activities in scope for the stepped care model.

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Figure 2 – Stepped care model

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What does the model mean for consumers?

What does the model mean for services?

The model depicts a system in which consumers

access a range of well-coordinated services of

varying levels of intensity, delivered in a way

that is appropriate in the context of each

individual personal circumstances.

The model depicts a system in which a range of

different service elements are efficiently

delivered at lowest level intensity appropriate to

individual needs, at the earliest possible point in

a consumer’s illness.

Case study (TBC)

Case study (TBC)

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4.3. Service access and coordination

The stepped care model described in Figure 2 focuses on articulating the range of key service

elements available to people with different needs. Effective pathways into and between services

are also a critical feature of the model overall, and will be supported through the operation of a

centralised information, intake assessment and referral service. The primary pathways into and

through the system are shown in Figure 3.

Figure 3 – Consumer pathways

The approach to service access and coordination is consistent with the key principles that

underpin the stepped care model. The information, intake assessment and referral approach will

be person-centred, adopting a no-wrong-door approach with multiple possible entry points, and

coordinated, offering efficient linkage to a range of service elements of different intensities

over a person’s recovery journey. This supports consumers to access appropriate services in a

timely and efficient way, while minimising duplicative contact.

In addition to articulating what consumers can expect from their pathway through the system, a

coordinated approach articulates the roles and responsibilities for services, including relevant

communication and information sharing channels.

Exiting from the stepped care model does not mean a ‘hard exit’ from mental health services

and supports, but rather a step down to natural supports. Exit does not preclude someone from

re-entering the stepped care model in the future if their needs change.

Table 2 sets out the key design parameters for the information, intake and referral service, and

the expected outcomes that follow from its implementation. Key design parameters are high-

level descriptions of the critical aspects of a service and guide the subsequent development of

service model or detailed specifications.

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Table 2 – Information, intake and referral: key design parameters

Key design parameters Outcomes

Information,

intake and referral

The purpose of this

service element

will be to provide a

single point of

access for

information,

linkage and referral

to services

available through

the primary mental

health care system.

Consumers, natural supports and service providers can access a single point of

information about available services either online and by telephone.

Consumers can self-refer to the intake service and be connected in a timely way

to appropriate service elements. Where service elements are not immediately

available (e.g. due to wait lists), consumers are linked to interim supports.

Consumer contact will be with appropriately skilled and qualified clinical staff

able to undertake preliminary needs assessments and determine the most

appropriate point of immediate referral. Staff also undertake risk assessments

and connect people to crisis service where there is high and imminent risk of

self-harm.

Care-coordination type service providers (including GPs) can connect consumers

to service elements that make up a person’s care plan/recovery plan through

the intake and referral service.

Consumers will be connected to care-coordination services as a priority after

assessment, where these are necessary and not already in place.

Service providers must refer consumers through the service to access SEMPHN

funded services and programs.

The service collects key data from consumers and providers on episodes of care

and outcomes consistent with the Minimum Data Set. These SEMPHN funded

services and programs (and others by negotiated agreement) will provide data

on episode commencement and closure, and on consumer outcomes.

Data collected by the intake and linkage services will be available to services

(with consumer consent) to minimise duplication and repetition.

The service complements (rather than duplicating) existing system entry points

and processes, including entry via specific services.

Consumers experience well-

coordinated services as

they move through the

stepped care model

Service providers and

clinicians experience a

well-coordinated system

Consumers access

appropriate mental health

care in modalities aligned

to their individual needs

Consumers access flexible

services at times and places

that meet their needs

Consumers and those

supporting them have a

good experience when

accessing support, care and

treatment

Resources available to the

system are deployed

sustainably and efficiently

Downstream costs of care

decrease through earlier

intervention

CONTENTS

5. Operationalising the model

5.1. Governance

The SEMPHN Board oversights the implementation of the stepped care model, and in delivering

this mandate receives advice as appropriate from the Clinical and Community Councils

established by the PHN. The SEMPHN Executive are accountable for the implementation of the

stepped care model. Specific service elements implemented under the model will be expected

to have arrangements in place to ensure appropriate levels of clinical governance, quality and

risk management.

The proposed governance arrangements are summarised in Figure 4.

Figure 4 – Governance arrangements

5.2. Implementation approach

South Eastern Melbourne PHN has been tasked with a regional leadership role in primary mental

health care, and will have overall responsibility for advocating and enabling the implementation

of the stepped care model.

This will involve SEMPHN directly commissioning and funding some services (e.g. low intensity

services, targeted psychological therapies, clinical care coordination), but also extends to

regional planning, coordination and service integration (e.g. regional suicide prevention).

While this document sets out the aspirations for the stepped care model, implementation will be

staged. An early priority will be commissioning targeted psychological therapies and clinical care

coordination services and ensuring a smooth transitioning from the Access to Allied Psychological

Services (ATAPS) and Mental Health Nurse Incentive Program (MHNIP).

CONTENTS

Figure 5 provides an overview of the implementation approach. The implementation approach

will be established in a companion document, the SEMPHN Mental Health Stepped Care

Commissioning Plan (the Commissioning Plan).

The Commissioning Plan will include what is being commissioned, when and how. Drawing on

the stepped care model, it will include high-level specifications for system elements (or groups

of system elements) being commissioned, including the purpose, general scope and service

parameters, key design features and intended outcomes, and relationship to the stepped care

model.

Implementation will be supported by extensive workforce-readiness campaign led by the PHN.

This will included targeted education for GPs, practice managers, allied health providers and

others engaged in primary mental health service delivery.

Figure 5 – Implementation of the Stepped care model

5.3. Program transition

The introduction of the stepped care model will result in some existing services and programs

moving into the model, or where programs cease, consumers will need to be transitioned to new

supports. While the stepped care model describes the intended end state, transitional

arrangements are likely to be in place for some services to ensure minimal disruption to

consumers.

Service element working groups will have responsibility for identifying transition issues and

developing strategies to maintain continuity of service, with input from clinical and consumer

advisory groups as appropriate.

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6. Telling the story

6.1. Introduction

A key tenet of successful implementation of the stepped care model is a commitment to

monitoring and evaluation. Monitoring and evaluation serve two key purposes:

maintaining accountability to consumers and their support networks, the community and

funders

providing data to inform ongoing implementation and future design improvements.

Gathering the right data will allow a ‘performance story’ to be told about how well the system is

operating and the extent to which it is achieving its intended outcomes.

6.2. Measuring outcomes

The outcomes framework for the stepped care model is set out in Table 3 over the page.

The stepped care model design principles articulated in section 4.1 are intended to result in the

achievement of key long term outcomes for consumers and for the system overall. Indicators are

included for each outcome that will signal change in the long-term outcomes.

However, many of these outcomes may take some time to be realised. To allow for progress to

be monitored, lead indicators are also proposed within this framework to provide an earlier

picture the trajectory of achievement. These indicators are indicated by the ▲ symbol, and are

those expected to show positive change within three years.

6.3. Reporting on performance

The outcomes framework will support SEMPHN to tell the ‘performance story’ for the region’s

primary mental health services. The key indicators that make up the framework provide insight

into different dimensions of performance, and will capture significant changes over time.

Analysing system performance enables targeted effort to improve areas of underperformance,

and provides a form of systemic accountability. The complexity of the health system, and the

socio-economic environment it is situated within, mean that there are many factors that can

lead to changes in indicators. The extent to which SEMPHN is able to directly influence indicator

results will vary.

Once specific measures are developed for each indicator, regular reports on system performance

will be published by SEMPHN to ensure system accountability to the community.

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Table 3 – Stepped care model outcomes framework

Long term outcomes Proposed indicators PERSO

N-C

EN

TRED

NESS

Consumers and those supporting them have a good

experience when accessing support, care and

treatment

Consumer satisfaction with primary care services ▲

Natural Supports satisfaction with primary care services ▲

Consumer satisfaction with referred services ▲

Consumers experiencing social disadvantage access

care on an equitable basis Service utilisation rates by population sub-groups

Distribution of centres of service provision ▲

Consumers access services that are culturally safe

and age-appropriate

Consumer satisfaction with primary mental health services by sub-group

Utilisation rates for sub-group targeted services ▲

Utilisation rates for interpreter services ▲

Consumers have choice and control over their mental

health service access as far as is reasonable

Distribution of services

Consumer satisfaction with care planning and coordination

EFFECTIV

EN

ESS Consumers experience improved mental health and

wellbeing outcomes

Population rates of subjective wellbeing

Population rates of psychological distress

Reported clinical outcomes from primary mental health care ▲

Rates of self-harm and suicide in at-risk groups are

reduced

Age-standardised rate of death by suicide

Emergency department presentations relating to intentional self-harm

Hospital admissions relating to intentional self-harm

FLEXIB

ILIT

Y

Consumers access to appropriate mental health care

in modalities aligned to their individual needs

Service utilisation rates by diagnosis and functional ability

Service utilisation rates by low, moderate and high intensity services ▲

Service utilisation rates by modality

Consumer satisfaction by low, moderate and high intensity services ▲

Consumers access flexible services at times and

places that meet their needs

Service utilisation after-hours ▲

Consumer self-reported difficulty accessing health services ▲

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EFFIC

IEN

CY

Resources available to the system are deployed

sustainably and efficiently

Rates of referral completion ▲

Rates of service episode completion ▲

Service element continuity over time

Services are available equitably across the region Ratio of key mental health professions to population

Distribution of centres of service provision

Service utilisation rates by geography ▲

TIM

ELIN

ESS

Downstream costs of care decrease through earlier

intervention

Avoidable hospital admissions related to mental health

Hospital admissions related to intentional self-harm

Avoidable emergency department presentations related to mental health ▲

Consumers access needs-appropriate mental health

care in a timely way

Consumer self-reported difficulty accessing health services ▲

Natural Supports self-reported difficulty accessing health services ▲

Waiting times to appointments with mental health professionals

Avoidable emergency department presentations related to mental health

CO

ORD

INATIO

N

Consumers with mental illness experience

improvement in cultural, physical and social

outcomes

Consumer physical health status on key markers

Consumer economic participation

Consumer social participation and personal connectedness

Consumers experience well-coordinated services as

they move through the stepped care model

Consumer satisfaction with referred services ▲

Consumer satisfaction with care coordination ▲

Population rate of mental health plans ▲

Service providers and clinicians experience a well-

coordinated system

Service satisfaction with referral and care coordination pathways ▲

▲ Indicators expected to show positive change within 3 years.

SEMPHN MENTAL HEALTH STEPPED CARE MODEL_SEMPHN WEBSITE FINAL SERVICE ELEMENTS 25

7. Service elements

This section provides a concise description of the key service elements that make up the stepped care model. At this stage of drafting this

section reflects the range of services described as in-scope within the Commonwealth’s guidelines, although these may be amended in

consultation with SEMPHN and stakeholders.

GENERAL ADULT SERVICES

Service element Service element description

Community-based suicide risk identification and prevention

The purpose of this element is to support existing community-based suicide risk identification and prevention through workforce training and education, particularly for system ‘gatekeepers’, and providing follow-up and support for adults who have self-harmed or attempted suicide.

Self-directed digital MH services The purpose of this service element is to provide online support services for adults experiencing, or at risk of, mild mental illness.

Low intensity peer-led interventions The purpose of this service element is to provide low intensity interventions for adults with, or at risk of a mild mental illness.

Clinician supported digital MH services The purpose of this service element is to provide clinician supported online mental health services for adults with moderate mental illness.

GP-led care coordination The purpose of this element is to provide clinical care coordination for adults with a mild-moderate mental illness.

Linkages to broader social supports The purpose of this service element is to link adults experiencing mild-severe into the broader social supports necessary to live a meaningful life.

Higher intensity peer-led interventions

The purpose of this service element is to provide additional support for adults experiencing a moderate-severe mental illness than is otherwise provided through GP/psychiatrist coordinated care, including the Better Access initiative.

Complex care and support coordination The purpose of this service element is to provide support for a mental health professional to provide a care coordination role for people with severe and complex mental illness, in community-based general practices, private psychiatrist services and other appropriate services.

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CHILDREN AND YOUTH SERVICES

Service element Service element description

Youth targeted suicide risk identification and prevention

The purpose of this element is to support existing community-based suicide risk identification and prevention targeted at children and young people, through workforce training and education, particularly for system ‘gatekeepers’, and providing follow-up and support for young people who have self-harmed or attempted suicide.

Age-appropriate digital MH services The purpose of this service element is to provide online support services for children and young people experiencing, or at risk of, mild mental illness.

Early intervention services for young people at risk of severe mental illness

This service element will provide early intervention services designed for young people at risk of severe mental illness.

Clinician supported age-appropriate digital MH services

The purpose of this service element is to provide clinician supported online mental health services for children and young people with moderate mental illness.

Children and youth focused brief psychological interventions

The purpose of this service element is to provide brief, focused psychological services for young people aged over 12, who are experiencing mild-moderate mental illness.

GP-led care coordination (e.g. Doctors in Schools)

The purpose of this element is to provide clinical care coordination for young people aged 12-25 with a mild-moderate mental illness.

Linkages to broader social supports The purpose of this service element is to link children and young people experiencing mild-severe into the broader social supports necessary to lead a meaningful life, including vocational support and AOD services.

Family Mental Health Support Services The purpose of this service element is to improve mental health outcomes for children and young people by supporting families and young people who are at risk of, or experiencing mental illness.

Extended children and youth focused psychological interventions

The purpose of this service element is to provide additional psychological interventions for children and young people experiencing a severe mental illness, whose needs are not sufficiently met through brief, focused psychological interventions. The service element will provide additional therapeutic interventions and/or support from clinical psychologists.

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Early intervention services for young people with severe mental illness

This service element will provide early intervention services designed for young people experiencing the early stages of severe mental illness.

Specialised complex care and support coordination

The purpose of this service element is to provide support for a mental health professional to provide a care coordination role for young people aged 12-25 with severe and complex mental illness, in community-based general practices, private psychiatrist services, and other appropriate services.

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SERVICES TARGETING SOCIALLY DISADVANTAGED POPULATIONS

Service element Service element description Targeted resilience building and mental health literacy programs

The purpose of this service element is to provide targeted health promotion to support resilience building and mental health literacy within key cohorts.

Cohort-targeted suicide risk identification and prevention programs

The purpose of this element is to support and supplement existing community-based suicide risk identification and prevention (with a focus on socially disadvantaged cohorts) through workforce training and education, particularly for system ‘gatekeepers’, and providing follow-up and support for adults who have self-harmed or attempted suicide.

Affordable and accessible brief psychological interventions

The purpose of this service element is to provide brief, focused psychological services for people in financial hardship who are experiencing mild-moderate mental illness.

Cohort-specialised GP-led care coordination The purpose of this element is to provide clinical care coordination for adults with a mild-moderate mental illness.

Active outreach and engagement services for hard-to-reach populations

The purpose of this service element is to provide additional support for engagement activities and outreach services for hard-to-reach populations.

Linkages to cohort-appropriate social supports

The purpose of this service element is to link socially disadvantaged people experiencing mild-severe into the broader social supports necessary to lead a meaningful life, including vocational support and AOD services.

Affordable and accessible extended psychological interventions

The purpose of this service element is to provide additional psychological interventions for adults in target cohorts experiencing a severe mental illness, whose needs are not sufficiently met through brief, focused psychological interventions.

Cohort-specialised complex care and support coordination

The purpose of this service element is to provide support for a mental health professional to provide a care coordination role for people from targeted cohorts with severe and complex mental illness, in community-based general practices, private psychiatrist services, and other appropriate services.

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ABORIGINAL AND TORRES STRAIT ISLANDER SERVICES

Service element Service element description

Aboriginal and Torres Strait Islander targeted cultural strengthening and social and emotional wellbeing programs

The purpose of this service element is to provide social and emotional wellbeing programs. These programs are designed to engage Aboriginal people in developing resilience and protective factors through cultural strengthening.

Aboriginal and Torres Strait Islander targeted suicide risk identification and prevention programs

The purpose of this element is to support and supplement existing community-based suicide risk identification and prevention for Aboriginal and Torres Strait Islander people through workforce training and education, particularly for system ‘gatekeepers’, and providing follow-up and support for adults who have self-harmed or attempted suicide.

Culturally appropriate, self-directed digital MH services

The purpose of this service element is to provide online support services for Aboriginal and Torres Strait Islander people experiencing, or at risk of, mild mental illness.

Culturally appropriate Natural supports Mental Health Support Services for young people

The purpose of this service element is to improve mental health outcomes for Aboriginal and Torres Strait Islander children and young people by supporting families and young people who are at risk of, or experiencing mental illness.

Clinician/AHW supported culturally appropriate digital MH services

The purpose of this service element is to provide supported online mental health services for Aboriginal and Torres Strait Islander people with mild-moderate mental illness.

Culturally appropriate brief psychological interventions

The purpose of this service element is to provide culturally appropriate, brief, focused psychological services and other culturally appropriate psychological interventions for Aboriginal and Torres Strait Islander people in financial hardship who are experiencing mild-moderate mental illness.

Culturally appropriate GP-led care coordination

The purpose of this element is to provide clinical care coordination for Aboriginal and Torres Strait Islander adults with a mild-moderate mental illness. This service element will provide additional support for workforce development to enable GPs to provide effective care coordination across multiple morbidities and services.

ACCHO-led care coordination The purpose of this element is to provide clinical care coordination for Aboriginal and Torres Strait Islander adults with a mild-moderate mental illness.

Linkages to cultural and social supports The purpose of this service element is to link Aboriginal and Torres Strait Islander people experiencing mild-severe into the broader social supports necessary to lead a meaningful life, including cultural and social and emotional wellbeing services.

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Culturally appropriate extended psychological interventions

The purpose of this service element is to provide additional psychological interventions for Aboriginal and Torres Strait Islander adults experiencing a severe mental illness, whose needs are not sufficiently met through brief, focused psychological interventions.

Culturally appropriate complex care and support coordination

The purpose of this service element is to provide support for an appropriately qualified mental health professional to provide a care coordination role for Aboriginal and Torres Strait Islander people with severe and complex mental illness, in community-based general practices, private psychiatrist services, ACCHOs, and other appropriate services.

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APPENDIX A REFERENCES

REFERENCES CITED

Commonwealth of Australia. (2010). National Standards for Mental Health Services.

Department of Health. (2015). Australian Government Response to Contributing Lives,

Thriving Communities: Review of Mental Health Programmes and Services

Department of Health. (2016a). PHN Mental Health Guidance: Aboriginal and Torres Strait

Islander Mental Health Services

Department of Health. (2016b). PHN Mental Health Guidance: Consumer and Carer

Engagement and Participation

Department of Health. (2016c). PHN Mental Health Guidance: Low Intensity Mental Health

Services

Department of Health. (2016d). PHN Mental Health Guidance: Psychological Therapies

Provided by Mental Health Professionals to Underserviced Groups

Department of Health. (2016e). PHN Mental Health Guidance: Regional Approach to

Suicide Prevention

Department of Health. (2016f). PHN Mental Health Guide: Child and Youth Mental Health

Services.

Department of Health. (2016g). PHN Primary Mental Health Care Guidance: Stepped Care

Department of Health. (2016h). PHN Primary Mental Health Care: People with Severe

Mental Illness.

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Department of Health. (2016i). Primary Health Network: Grant Programme Guidelines -

Annexure A1 Primary Mental Health Care

Department of Health. (2016j). Primary Health Networks: Grant Programme Guidelines

Department of Health and Human Services. (2015). Victoria's 10-year Mental health Plan

Department of Social Services. (2015). Family Mental Health Support Services Retrieved

from https://www.dss.gov.au/our-responsibilities/mental-health/programmes-

services/family-mental-health-support-service-fmhss

Harris, M., et al. (2016). Rapid Literature Review: Primary Mental Health Care Models

Mazza, D., et al. Identifying the Most Effective Models of Care for the Management of

Mild to Moderate Depression in Primary Care: A rapid review, Department of

General Practice, Monash University.

Mazza, D., et al. (2016). Identifying the Most Effective Models of Care for the

Management of Eating Disorders in Primary Care: A Rapid REview

National Disability Insurance Agency. (2015). Final Project Scope: Outcome Measures and

Reference Packages for Psychosocial Disability

South Eastern Melbourne PHN. (2016). South Eastern Melbourne PHN: Needs Assessment

Reporting Template - Mental health

The Black Dog Institute. (2016). An Evidence-based System Approach to Suicide

Prevention: Guidance on Planning, Commissioning and Monitoring