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New shoots: pilot program offers hope for better care for people with serious mental illness

In her final report from the recent Equally Well 2022 Symposium, Cate Carrigan profiles a promising pilot program for people with serious mental illness, as well as other efforts to provide holistic care.


Cate Carrigan writes:

A program providing proactive support and follow-up care for people with serious and persistent mental illness in north-west Melbourne has shown the value of a coordinated, multidisciplinary approach to improving physical health, with consumers feeling valued and listened to.

The Integrated Chronic Care (ICC) pilot “stood out as providing a caring, compassionate and human connection in a service system where this was a rarity”, reported an evaluation of the program.

The program was funded by North Western Melbourne Primary Health Network (NWMPHN) and delivered by Neami National and cohealth from July 2019 to August 2021, with each service employing a registered nurse and a mental health peer worker, on fractional appointments.

“The data consistently indicate that the ICC model has significant potential,” reported the evaluation. “Overwhelmingly, consumers gave very positive appraisals, and professional stakeholders confirmed high and untapped demand. Both ICC programs were praised for providing compassion in an otherwise uncaring system.”

The evaluation, which was led by RMIT University’s Social and Global Studies Centre, also demonstrated the challenges of trying to improve care and outcomes for these patients when there are so many gaps in mental and physical healthcare systems.

“The poorly functioning mental health system was only one side of the issue, exacerbated by a systemic lack of specialist pain management services and an absence of incentives for general practitioners to engage with people in the ICC target group,” reported the evaluation.

As well, the experiences of many consumers are so complex that healthcare coordination alone is insufficient to address their needs when they are also dealing with needs for housing, family violence support and legal systems, the evaluation found.

The challenges for the program were even more difficult because of the coronavirus restrictions then in place.

Useful outcomes

Photo of Dr Johnson
Dr Johnson

Dr Caroline Johnson, a Melbourne-based GP and senior lecturer in General Practice at the University of Melbourne, presented on the pilot program and its evaluation at the recent Equally Well Symposium.

“The pilot encountered people in the region who had incredibly complex physical and mental health issues intertwined and who were really struggling to access the right mix of physical and mental healthcare,” she said.

Johnson told Croakey that people who use mental health services in north-west Melbourne have a life expectancy of 52 years – 30 years lower than the Australian population.

“The pilot aimed to ensure consumers received appropriate physical and mental healthcare service and supports to improve outcomes for their chronic conditions and be empowered in self-management of their health,” she said.

Consumers were offered care coordination with input from a nurse and peer worker, to assess goals for physical health and identify any barriers they might be experiencing, with pro-active support and follow-up being the key ingredient for both providers.

“We wanted to find out what consumers really needed and facilitate that within a complex and often under-resourced system”, she said.

Johnson said the intervention was “very well received by consumers and the impact of feeling listened to, cared for and understood were highly valued”, and GPs and nurses noting the high demand for this type of support.

Although the pilot didn’t measure specific quantitative physical health outcomes – with the pandemic hampering data collection, Johnson said those involved did see the precursors of change.

Despite the difficulty in both achieving and then measuring changes in health outcomes, the report noted there was a significant increase in screening, adding that much of the decreased life expectancy in people with mental illness is due to reduced screening due to diagnostic overshadowing.

There was “great potential to lead to tangible health outcomes, such as changing attitudes to health, increased health literacy and increased access to appropriate health services,” she said.

Ongoing challenges

Johnson said the pilot helped confirm ongoing challenges around the fragmentation and duplication of services and of providers often working on short-term contracts in under-resourced environments.

“It is also clear that more work needs to be done to define the role of the peer workforce in this type or work, and in particular the type of support the peer workforce needs to achieve its potential in the future,” she added.

Johnson’s message to delegates was the value of taking a multidisciplinary approach and the “awesome experience” of working with skilled evaluators and lived-experience researchers, as well as other clinicians.

“That sharing of ideas and perspectives made for a very rich understanding of how the intervention played out in the real-world,” she said.

While ongoing funding for this approach is a decision for NWMPHN, Johnson was hopeful the pilot would inform the further development of mental healthcare services.

“Demonstrating improved health outcomes for people with serious and persistent mental illness will need a longer and stronger focus on measuring change over time, something that a pilot of this size and duration, impacted as it was by the pandemic, was not able to achieve.

“The pilot tells us what is needed next to achieve best-practice, in particular the need to do more to integrate care coordination with other primary care services, to fund adequately and for longer time-frames that minimise staff turnover and allow for development of a clear model for peer work for mental and physical health,” she said.

Among the report’s recommendations were best-practice screening; strategies to improve equity of access; care coordinators having expertise in both physical and mental healthcare; support and training of peer workers; service integration including co-location with NGO or primary care services rather than public mental health services; and adequate funding of future pilots to minimise staff turnover and to meet potential demand.

Lived experience

The symposium also saw the release of a joint Lived Experience Australia and Equally Well report into mental health consumers and carers’ experience of the healthcare system.

The report found only one in five consumers were asked about their physical health by their mental health professional, and that only 52 percent of those health professionals took consumers’ concerns about physical health seriously.

Only 55 percent of respondents reported that mental health professionals showed interest outside of their mental health diagnosis (for example, in their social connection, community participation), and only 53 percent of respondents reported that mental health professionals paid attention to their concerns about the physical side-effects of their medications.

The figures were better when it came to GPs and allied health professionals, with the report finding 84 percent of GPs and 81 percent of allied health professionals asked about the physical health of those with mental ill-health conditions.

However, the report went on to say that survey responses suggested there is still a significant proportion of the population who are not being asked or screened for basic physical health risks such as cancer screening (47 percent), or whether they smoked.

Other key findings included carers being largely excluded from consumers’ care planning (51 percent), and many people with mental illness not being able to afford to see a health professional when they needed to (68 percent).

Living well and longer

Andy Simpson, program manager with Sydney Local Health District’s Living Well Living Longer program, told the conference about a four-stage process aimed at improving the physical health of people with severe mental illness.

Launched in 2014, the program is part of SLHD’s commitment to ensuring people with severe mental illness have equitable access to the same high quality health care as the general population, including access to primary and secondary care and highly specialised health care.

An initial assessment sets up physical health goals; metabolic screening, to measure waist, weight etc, is undertaken; and shared care is set up with mental health service and GP, followed by a comprehensive cardio-metabolic check by the Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHIP), a one-stop shop multidisciplinary clinic.

Simpson said peer support workers also facilitate weekly group meetings or outings, such as swimming, yoga or walking; there is follow-up metabolic screening and a ccCHIP and psychiatry review.

Through the Living Well Living Longer program, consumers have access to community lifestyle clinicians, such as dietitians, exercise physiologists, and smoking cessation officers, who work with them to develop individualised achievable and relevant health behaviour change.

Andy Simpson

The program is built around an annual cycle, with Simpson explaining consumers are referred back to ccCHIP every twelve months and follow-up recommendations are sent to GPs for action.

“It is remarkable how every week they discover someone they suspect has probably had untreated diabetes for ten years – literally it’s a weekly occurrence,” said Simpson.

Since the program started in 2014, more than 1,100 individuals have been reviewed at ccCHiP, 1,200 enrolled in Mental Health Shared Care, and over 2,100 have engaged with the lifestyle clinicians.

Simpson said the number of consumers undergoing physical health checks had doubled since the start of the program and the number of people who had seen a GP in the last six months had risen from two to 50 percent.

Comparing data from 2016 and 2020, he reported improvements in weight and metabolic measures.

Panel perspectives

Symposium participants heard from panels discussing some of the big topics and providing insightful pointers from consumers, services providers and researchers.

Panel (L to R): Vicki Langan,Fay Jackson, Andrew Watkins, Dr Caroline Jackson

Below are some key takeaways from a panel on ‘Overcoming implementation barriers’.

Fay Jackson: General manager inclusion at Flourish Australia and former deputy commissioner for the NSW Mental Health Commission.

“Culture is a ‘problem and a killer’ in stopping the recognition and treatment of the physical health needs of those of us with mental health conditions. There is a culture in the community and health services that “so long as we are quiet and not causing a fuss then everyone is happy”.

We need a culture that’s open and understanding and values members of our family and community.

We need more peer workers to drive cultural change.

Let’s give peer workers Medicare provider numbers and set up share-care services in GP practices where a group of consumers can meet with a GP, nurse, psychiatrist and peer workers, and talk about physical health.

Doctors need to know that building relationships with consumers is a very powerful tool and that medication is not the only answer.”

Vicki Langan: NSW Health promotion and wel