Early Psychosis Services across Australia

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2 Early Psychosis Services across Australia Stanley Catts University of Queensland Ninth NSW Early Psychosis Forum 3 November 2005

3 Overview Brief description of C-PIN EP National Census of Early Psychosis Initiatives Service Self-Review Instrument results from the 15 early psychosis teams in the prospective evaluation Models of early psychosis services Preliminary conclusions

4 An Australian multi-site evaluation of EP programs The NHMRC Clinical Practice Improvement Network for Early Psychosis Chief Investigators Stanley V. Catts* Brian I. O Toole** Vaughan J. Carr*** Associate Investigators Terry Lewin*** Amanda Neil*** Meredith Harris**** *U of Queensland; **U of Sydney; *** U of Newcastle; ****ORYGEN Youth Health

5 The NHMRC Clinical Practice Improvement Network for Early Psychosis (C-PIN EP ) C-PIN EP is an epidemiological study of the effect of exposure to guidelineadherent early psychosis intervention The study used a prospective observational cohort design C-PIN EP was approved as a quality assurance project, not requiring patient consent

6 C-PIN EP Data Sources Service Level Service Census Service Self Review Instruments Case Manager Feedback Questionnaire Patient Level Recording Forms Service Contact Forms HoNOS, LSP, Consumer Measures Chart Audit Consumer and Carer Feedback Questionnaires

7 Project Design

8 Approach to Analysis (Hierarchical Linear Modelling) Multi-Level Modelling Treating Team Level Information Patient Level Information Census EP Indicators Health Outcomes Clinical Practice Level Information SCF

9 Early Psychosis (EP) services across Australia Across-service levels of reported EP service implementation (Census) Within-service relationships between Director s priorities and consumer/clinician reported EP functions (SSRI) Qualitative review of apparent EP service models

10 National Early Psychosis Initiative Census

11 Census Returns Australia. Australian Capital Territory. New South Wales Northern Territory. Queensland.. South Australia. Tasmania.. Victoria.. N Areas Sectors n % N n % Western Australia

12 Developing an EP function Australia Training 88% Flagging system Appointed coordinator Aollcated resources 55% 54% 55% Policies/Guidelines 70% Literature review Key dates 53% 53% Implementation Plan 59% Stategic Plan 75% Discussion paper 32% Service review 71% File audit 51% 0% 20% 40% 60% 80% 100%

13 Developing an EP function New South Wales Training 91% Flagging system 78% Appointed coordinator Aollcated resources 63% 68% Policies/Guidelines 75% Literature review 64% Key dates Implementation Plan 77% 78% Stategic Plan 88% Discussion paper 34% Service review 84% File audit 59% 0% 20% 40% 60% 80% 100%

14 Developing an EP function Victoria Training 89% Flagging system 38% Appointed coordinator 75% Aollcated resources 63% Policies/Guidelines 89% Literature review Key dates Implementation Plan 56% 56% 56% Stategic Plan 88% Discussion paper 56% Service review 78% File audit 56% 0% 20% 40% 60% 80% 100%

15 Developing an EP function Queensland Training 80% Flagging system 10% Appointed coordinator Aollcated resources 20% 22% Policies/Guidelines 30% Literature review Key dates 0% 10% Implementation Plan 22% Stategic Plan 40% Discussion paper 10% Service review 40% File audit 10% 0% 20% 40% 60% 80% 100%

16 Developing an EP function Northern Territory Training 100% Flagging system Appointed coordinator Aollcated resources Policies/Guidelines Literature review Key dates Implementation Plan Stategic Plan Discussion paper Service review File audit 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 20% 40% 60% 80% 100%

17 Proportion of services with no, partial, and comprehensive EP functions Number of infrastructure elements in place*: AUST 6% 22% 13% 35% 24% VIC 13% 13% 13% 25% 38% NSW 9% 19% 41% 33% QLD 20% 50% 10% 20% WA 100% SA 100% TAS 100% NT 100% 0% 100% * Allocating resources, appointing coordinator, developing a flagging system, and training

18 Allocation of services budgets to EP Per capita spending on EP Proportion of budget allocated to EP Australia.. Australian Capital Territory.. New South Wales.. Northern Territory.. Queensland South Australia.. Tasmania Victoria Western Australia.. $ $0.53 $0.00 $0.05 $0.09 $0.00 $0.21 $ % % 0.00% 0.10% 1.02% 0.00% 0.39% 0.35%

19 The comprehensiveness of EP functions were not associated with any of the following service characteristics: Having an outreach function in the generalist case management team (t(39)= -.870, p>.05) Having specialised non-medical staff delivering discipline-specific interventions (t(36)= , p>.05) The ratio of doctors to catchment population (r=.212, p>.05) The ratio of vehicles to catchment population (r=.189, p>.05) The ratio of beds to catchment population (r=-.235, p>.05) The caseload of generalist case managers (r=.025, p>.05) The size of the catchment area population (r=.109, p>.05) The per capita mental health budget (r=.226, p<.166)

20 The most comprehensive EP functions were found in services that had: Extended hours capability (t(42)=-2.535, p<.05) 24-hour contact capability (t(41)=-2.587, p<.05) An Assertive Case Management Team (ACT) (t(31)=-2.967, p<.01) An outreach function in the ACT team (t(36)=-3.854, p<.01) Larger caseloads in the ACT team (r=.401, p<.05) A higher ratio of non-medical staff to catchment population (r=.310, p<.05). A higher overall mental health budget (r=.317, p<.05) Higher budget allocation to EP (r=.436, p<.01) Higher per capita spending on an early psychosis (r=.562, p<.01)

21 Service Self Review Instrument (SSRI) Manager Version Clinician Version Consumer Version

22 Assessing the ACG-EP All services participating in C-PIN EP evaluated for: Priority and level of implementation of the 10 EP guidelines Criteria and strategies supporting the 10 EP guidelines

23 Preliminary SSRI Findings (1) Consumer representative having a copy of the ACG-EP (Consumer SSRI) Increased initial service referrals of EP by family and friends (Manager SSRI)

24 Preliminary SSRI Finding (2) Range of community-based treatment settings available to the client (Manager SSRI) Family/carers contacted within 48 hours of initial assessment (Consumer SSRI)

25 Preliminary SSRI Finding (3) Range of community-based treatment settings available to the client (Manager SSRI) Inclusion of the family throughout the treatment process (Consumer SSRI)

26 Preliminary SSRI Finding (4) Information and educational sessions with community organisations (Clinician SSRI) Greater proportion of referrals from private psychiatry (Manager SSRI)

27 Models of early psychosis (EP) services 1. Treatment-as-usual 2. Limited EP service without integration 3a. Fully integrated EP service (limited EPI coverage) 3b. Fully integrated EP service (general EPI coverage) 4. Comprehensive EP service

28 Models of EP Services 1. Treatment-as-usual No early intervention focus No early detection function No routine EP registration system No EP intervention clinicians ± staff training

29 Models of EP Services 2. Limited EP service without integration ± Early intervention focus ± Early detection function ± Routine EP registration system + Limited EP intervention function serving selected patients using informal referral procedures + Staff Training

30 Models of EP Services 3a. Fully integrated EP service (limited EP intervention coverage) + Early intervention focus ± Early detection function + Routine EP registration system + EP intervention clinician capacity + Staff Training 3a uses time-limited brief EP intervention within existing resources augmented by no more than 2FTE EP clinicians per 250,000 of population

31 Models of EP Services 3b. Fully integrated EP service (general EP intervention coverage) + Early intervention focus ± Early detection function + Routine EP registration system + EP intervention clinician capacity + Staff Training 3b uses flexible duration EP intervention delivered to all EP patients, requiring resource augmentation of at least 10FTE EP clinicians per 250,000 of population

32 Models of EP Services 4. Comprehensive EP services + Early intervention focus + Early detection function + Routine EP registration system + EP intervention clinician capacity + Staff training and supervision + Specialist EP psychosocial group programs + Specialist EP inpatient program + Research and evaluation focus on EP

33 Preliminary conclusions (1) Directors reported significant implementation of early psychosis functions in about one-third of Australian mental health services The strongest predictor of implementation is the level of funding specifically allocated to early psychosis functions

34 Preliminary Conclusions (2) Service managers priorities and actions have a significant impact on EP service function.

35 Preliminary Conclusions (3) Five types of service models for EP patients could be distinguished: No specified EP functions Limited EP functions Fully integrated EP functions with limited coverage Fully integrated EP functions with general coverage Comprehensive

36 Preliminary Conclusions (4) Only six Australian AMHS appear to have fully integrated EP functions with general coverage (5) OR to represent a comprehensive EP service (1). It appears to require the addition of at least 10FTE clinicians per population to conventional AMHS resources to routinely provide EP intervention to all patients according to their need

37 Preliminary Conclusions (5) Finally. No service can aim at routine effectiveness evaluation without full-scale electronic clinical record keeping and indicator coding Only 2 AMHS have this capacity either generally implemented (Barwon Health) or specifically in support of early psychosis services (Fremantle Health Service)

38 Acknowledgements Project team Kathy Eadie Russell Evans Aaron Frost Belinda Schaefer This project is dedicated to mental health consumers, carers and service providers. They are the enduring inspiration for this work.