Physical health of those with serious mental illness.

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1 Physical health of those with serious mental illness. How Compass Health PHO is improving the service for our population Lynley Byrne Clinical Leader Compass Health PHO June 2016

2 Total Population Compass Network Total population: European/Pakeha Maori Pacific Other 8285 High Needs 60855

3 General Practices 53 across Wellington, Porirua and Kapiti 7 across Wairarapa

4 Community Health Services Primary Mental Health Outreach Nursing services School Based Health services Diabetes specialist nurses Podiatry Pacific navigation team

5 Community Health services Rheumatic fever Hep C Radiology Retinal Screening Sexual Health service SAATs LTC previously Care Plus now bulk funded

6 NZ Population NZ population is 4,684,578 1:5 will suffer MI 1,171,445 4% in spec services 468,578 96% in primary care 1,124,587 Compass Health Jan 2015-Jan 2016 = 4320 referrals for mild to moderate MH issues across 3DHB area for Compass Health (not Hutt Valley) Practice based MH staff increasing access to MH assessment and therapy/skills/brief interventions School based counsellor specialising in AOD and MH adolescent assessment and treatment

7 The future of Primary Mental Health WHO-depression will be 2 nd to IHD as most common disability by 2020 Co morbid LTC diseases such diabetes, CV disease, obesity often seen in MH population 2016 NZ stats indicate average life expectancy of women=88yrs and men 85 yrs, there is an 8.5 yr average decrease for Maori Average of 20 years less lifespan for MH population The future is not looking rosy for this population so we need to act now

8 PMH now Already around the country and here in Wellington and Wairarapa there are MH staff working in primary practice providing high quality service to the population within their own practice. Being able to be seen (assessed and provided tx) within GP practice within a two week timeframe is happening The barriers to this occurring in every practice is infrastructure and size of practices Development of localised health pathways for mental health would be of value to support primary care to deliver more MH services including information regarding the poor physical health outcomes and input required

9 Integration A small but significant step toward integration would be to allocate all primary practices to clinicians within CMHTs, in the same manner we have utilised in primary mental health, so every practice is aware of their PMH practitioner and can contact them when required Having a face to face relationship is the start of breaking down barriers and forming strong relationships Primary practices have MDTs regularly, and this would be a venue for secondary staff to attend to discuss any high needs/complex MH clients that require specialist knowledge and expertise My clinical work in high needs/low socioeconomic practice, attendance at practice MDT, advice to primary clinicians and comp diagnostic ax completed for those who require.

10 Integration and early intervention makes a difference to patient lives Early intervention in primary care can prevent later more serious issues Young man 20 yrs with 10 hx of AOD and legal issues Left school at 14, lived in many localities, heavy AOD use, had 3 month incarceration in Rimutaka prison for multiple crimes and failure to report to probation, released on electronic monitoring-very chaotic life Had never had comp assessment of MH needs or any specialist MH input, and had lived a very dysfunctional life from 10yrs I assessed as having had criteria for Conduct Disorder and referred to CMHT for ax and consideration of ADHD Is now on methylphenidate, minimal AOD, working, nil crime, changing his life

11 Report and self audit for practices Data analysis of how many patients on antipsychotics and mood stabilisers=8500 scripted in CH practices in past year Broken down into practice population And then matched with parameters so from chart easily seen who has had what tests in past 12 months to July 1 st Parameters evidence based from Nice guidelines and Maudsley Prescribing Guidelines-developed with primary health and DHB some time ago & updated at CCDHB, 2 years ago-still valid Medications -oral and IMI antipsychotics and three mood stabilisers- for annual physical FREE on LTC for those prescribed in primary care

12 Medications Clozapine Olanzapine Quetiapine Risperidone Ziprasidone Fluphenazine Flupentixol Risperidone Paliperidone Aripiprazole Zuclopenthixol Mood stabilisers Trifluperazine Pericyazine Haloperidol Amisulpride Chlorpromazine Lithium carbonate Sodium valproate Carbamazepine

13 Parameters to test BP and P Weight BMI Waist circumference FBC HbA1c Cholesterol HDL & Chol/HDL ratio Triglycerides LFTs Electrolytes Creatinine Prolactin TFTs Lithium drug monitoring 6/12ly Ask about constipation AIMs test

14 Report available on portal All practices can access the report on the provider portal, they can only access their patients which are in alphabetical order of NHI Parameters to be tested are across the top of report so gaps are easily seen and dates for last bloods also easily seen Plan is annual physical which will develop into a wellness check looking at wider parameters in following years This annual physical will identify those at risk of physical illness and treatment can be commenced and monitored as needed Initial conversation with MH Clinical leader at 3DHB re working together on this initiative, CH ready to roll out July 1st

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