The clinical redesign of community mental health in one of the sectors of SWAHS was identified as an area for improvement due to issues in service capacity. This was impacting on length of stay (LOS) of the inpatient unit as well as the number of clients seen by the service.

Contemporary change management practices were employed to successfully restructure two teams into a single integrated unit. As a result, an increase in the number of clients seen by the service has doubled.

The enhanced performance has improved the service’s ability to fulfil its clinical and corporate management responsibilities.

To increase by 50% the number of clients seen by the community mental health service in the western sector.

The Access and Transition teams in the western sector were two separate entities of community mental health that were established to provide client triage (known as the 1800), assessment and short-term follow-up (by the transition team) to clients of SWAHS Western Cluster, in particular the Penrith region.

A review of the current structure of the 2 teams identified that the current capacity was limited to following up a maximum of 10 clients for 10 days. Furthermore, state guidelines were not met. The issues noted by management were predominately affecting the region surrounding Penrith.

An assessment of current process was undertaken, the duties were split between the teams as follows:

• Access, the larger team with just over 10 staff, was responsible for maintaining the 1800 number, walk-in presentations to the centre, booked assessments and police presentations.
• The Transition team comprised of 4 clinicians who essentially managed up to ten acutely unwell clients for up to ten days before referring them on as required.
• All referrals to the transition team were through a medical officer only.
• Due to staffing levels and the natural evolution of practice the work was predominantly centre based.
• There was an inability due to current work processes and staffing levels to provide follow-up according to State policy 98/31 (now PD2005/121) for up to four weeks or 28 days post discharge from the inpatient unit (NSW Department of Health, 2004).

The redesign was imperative to achieve goals in line with National, State and SWAHS strategic directions. It also aimed at addressing issues of access and capacity.

The redesign of this service is in line with strategic direction 3: Strengthen primary health and continuing care in the community. The redesign of the service has improved access to mental health services.

Contemporary change management strategies were applied, these included:

• A consultative process took place on both group and individual basis. This was needed in order to discuss previous work conditions of employment (i.e.; some staff had been employed with negotiated reduction in hours which was in keeping with the area policy on flexible work practices).
• The Human Resources department reviewed working conditions of staff to ensure there were no breaches of conditions when changing the model of care provided.
• The group consultation brought together the two teams thus providing an open forum to discuss the required changes and progressively review implementation.
• Physical changes to the facility took place to create an intake room and interview room to allow for meetings and team handover. This also included minor refurbishments to client areas
• A handover process was introduced.
• All staff review management and clinical care of referrals twice a day. This has assisted the team to enhance clinical care for clients as well as discuss issues as a team.
• A whiteboard is used to visually manage and discuss the referrals to the service.

The teams merged in January 2008 and the new service model began with equitable distribution of tasks and responsibilities across all staff.

Staff now rotates through various workstations, operating as one larger unit. The various stations include phone intake (1800), walk in assessments and home visits/follow up.

Staff feedback informed adjustments to the model in subsequent weeks. The staff took ownership of the changes, utilising skills and experience to make constructive contributions, adjusting work practices whilst redefining their service provision.

Initial apprehension and concerns regarding changes to work conditions and possible demands were overcome through a close partnership between management and staff.

The changes have increased the capacity of the team to meet state requirements through extended management time frames of acutely unwell clients.

The graph below highlights the improvement pre-post implementation.

Prior to the service redesign, an average of 164 clients were seen by the service. Following the restructure, the service more than double the number of clients seen by the service. Current average is of around 336 clients.

Staff rotation through all clinical management areas enhanced the capacity of the team to maintain service provision. More equitable work distribution has increased staff satisfaction. The focus of care and service provision has moved from centre-based focus to the wider community.

Publicising of enhanced capacity to the inpatient facility has resulted in better discharge referrals.

Post discharge follow-up has assisted in reduced length of stay for some inpatient clients and enhanced the transition to community care. Carers have been clearly supportive of this change, as it maintains the least restrictive care whenever and wherever possible for consumers.

This enhanced capacity enables the team to better interface with other agencies such as police. Attending assessments in the community with police provides timely mental health interventions reducing the likelihood of hospital admission.

The redesign has been successfully implemented. It is expected that when current staff vacancies are filled in, including the addition of one new position through NSW Health Emergency funding, the team will be able to expand their follow up/home visiting capacity further.

Ongoing review of data will assist in maintaining motivation for the team and inform future directions.

It is anticipated that the new SWAHS mental health triage service will provide more available hours for face to face care provision with consumers, and support interagency links with police, and General Practitioners.

A review will take place within the next 12 months to review progress and support duplication of a similar service enhancement for the Katoomba region ACCESS services.

1. NSW Department of Health (2004), Framework for Suicide Risk Assessment and Management for NSW Health Staff, NSW Department of Health.
2. NSW Department of Health (2005), NSW Government Response to Tracking Tragedy 2004: 2nd Report of the NSW Mental Health Sentinel Events Review Committee. NSW Department of Health Website.
3. NSW Department of Health (2006), NSW: A New Direction for Mental Health. NSW Department of Health, North Sydney.
4. NSW Department of Health (2007), NSW Government’s Interim Response to Tracking Tragedy: 3rd Report of the NSW Mental Health Sentinel Events Review Committee. NSW Department of Health Website.

Associate Director - Clinical Governance, Clinical Governance Unit
Sydney West Area Health Service
Phone: 02 9881 7524