Jacques Esterhuizen - The Acute Community Intervention Team

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A presentation given by Jacques Esterhuizen at The Journey, CHA Conference 2012, in the 'Innovations in mental Health Care for Children & Young People'

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  • February 2011
  • Note Families at work is not part of acute services – it’s a specialised service
  • Average length of stay – 9.7 (08/09); 8.8 (09/10); 7 (10/11); 6 (11/12) Admission numbers – 193 (08/09); 214 (09/10); 274 (10/11); 358 (11/12) Referral source – Majority PMH ED Gender – 69% Female; 31% Male Ethnicity – 93% Other; 7% ATSI
  • Average length of stay – 19.5 (08/09); 17.1 (09/10); 11.3 (10/11); 12.3 (11/12) Admission numbers – 202 (08/09); 265 (09/10); 314 (10/11); 322 (11/12) Gender – 56% Female; 46% Male Ethnicity – 86% Other; 14% ATSI
  • Client numbers ???
  • 10 sites with multidisciplinary staff numbers ranging from 5.1 to 12.7 FTE per 100, 000 population ranging from 1.9 to 10.6 Colour range is numbers of population, so the darker the higher population in that area.
  • 16.6% of young people (Child Health Survey and Health and Wellbeing Study) and 21% of aboriginal young people (Aboriginal Child Health Survey) [12 to 17 years] have a mental health problem (emotional and behavioural disorders). 5% of young people (Child Health Survey) and 11% of aboriginal young people (Aboriginal Child Health Survey) have severe mental disorder. From Infancy to Young Adulthood- policy on child and adolescent mental health recommends CAMHS services (Tiers 3 and 4) provide services to the most severely disordered 2%. Current CAMHS capacity is approximately 1%.
  • The current population of Western Australia is approximately 2,100,000. About 500,000 (24%) are aged 0 – 17 years (projected from the Australian Bureau of Statistics, 21 June 2007, and the 2006 Census). About 74% of youth live in Perth and 26% in rural or remote areas. Indigenous children and adolescents constitute 6% of the entire population under 17 years; and 15% of the population in rural and remote regions.
  • Lengthy delays were identified when discharging a child who has presented to PMH emergency department before they could receive follow up in the community. Prior to the establishment of ACIT, children in need of intervention would have to be admitted or sent home pending an appointment with a community based care group or individual. Often this transfer of care did not happen in a smooth way and sometimes not at all. The end result was that children remained at risk and unsupported and often represented at the Emergency Department. ACIT conducts its business on the premise that: a proportion of admissions to Ward 4H may not be useful or justifiable, for example, containment of Department of Child Protection and other socially related situations, that there may not always be beds available on Ward 4H, that certain patients will not find it useful to be exposed to the problematic behaviour of others, that some patients clearly in need of intervention will refuse admission or maybe their parents will not give permission, for example, due to cultural stigma, that there is not an appropriate mix of gender in the ward's population.
  • Total referrals 08/09: 220 09/10: 209 10/11: 219 11/12: 295
  • Sep 09 – Aug 10 167 assessments; 38% (n=64) continued admission; 62% (n=103) discharged 47% (n=48) referred to ACIT 53% (n=55) referred to existing service CAMHS = 25.5% DCP = 18% BAU = 14.5% Private sector = 11% Other = 12.7% Sep 09 – Jun 10 Total = 127 Cont admit = 50 ACIT = 35 Other = 42
  • Jul 10 – Jun 11 Total = 211 Cont admit = 100 Discharge = 111 ACIT = 43 Other = 68 If ACIT not available then cont admit percentage would possibly increase to 68%
  • Expansion of ACIT after 3 month recruitment process Audit of last 3 months: Total clients: 63; 62; 79 High Acuity (week 1 and 2): 30%; 29%; 23% REFERRAL SOURCE Ward 4H: 33%; 34%; 27% PMH ED: 51%; 48%; 51% BAU: 10%; 10%; 15% Adult ED: 5%; 8%; 7%
  • 08-09 09-10 10-11 11-12 JUL 14 14 13 11 AUG 21 25 25 19 SEP 18 19 19 27 OCT 22 15 18 11 NOV 22 30 14 33 DEC 9 13 20 24 JAN 11 13 5 12 FEB 21 15 18 31 MAR 19 16 25 38 APR 14 9 23 16 MAY 26 16 19 38 JUN 23 24 20 35 220 209 219 295
  • Jacques Esterhuizen - The Acute Community Intervention Team

    1. 1. THE ACUTE COMMUNITYINTERVENTION TEAMJacques EsterhuizenAcute Services DirectorateCAMHSChild and Adolescent Health ServicesPerthWestern Australia
    2. 2. “It is not the strongest of the species that survive, northe most intelligent, but the one most responsive tochange” CHARLES DARWIN (1809-1892) Presentation  Layout of WA CAMHS services  Development of ACIT  Progress  Reform of inpatient units  Future directions
    3. 3. CAMHS Organisational Chart
    4. 4. Total clinicalFTE – 101
    5. 5. CAMHS inpatient beds: 28 beds for under 18yo for WA’s 2.4 million populationCAMHS area Ages (years) Number of bedsPMH Ward 4H under 16 8Bentley 12 to under 18 12Adolescent UnitFamilies at Work 6 – 12 8(sub-acute)
    6. 6. Acute CAMHS PMH Ward 4HClient group Type of Providing: serviceUp to 16 years Statewide Acute careThose who specialised Crisis admissioncannot be voluntary Can be followed bymanaged in the in-patient assessment forcommunity due service stabilisation, diagnosisto acuity or and planning forcomplexity of dischargeproblems Short interventions where indicated
    7. 7. Acute CAMHS Bentley Adolescent UnitClient group Type of service Providing:Up to 18 years State-wide Assessmentsold acute inpatient and treatments byThose who service a multidisciplinarycannot be Only team focusing onmanaged in the Authorised containment andcommunity due to mental health safety for younghigh level of acuity inpatient unit in peopleand risk WA for under 18’s
    8. 8. Acute CAMHS Transition UnitClient group Type of Providing: serviceAdolescents aged Step-down Intensive recovery13 to under 18 years facility focused programTransitioning Day Therapybetween BAU and program accessed byhome and/or into both inpatients andother services. outpatients Intensive group based work
    9. 9. CommunityCAMHS Clarkson, 6.5fte Swan Valley / Kalamunda Hillarys, 9.6fte 5.3fte Warwick, Bentley Family 9.3fte Clinic, 12.7fte Shenton, Armadale, 5.1fte 11fte Fremantle, 11fte Peel, Rockingham, 9.5fte 8.2fte Total clinical FTE – 88.2
    10. 10. Locations of CAMHS (WACHS)1.5 FTE West Pilbara 3.6 FTE West Kimberley3.5 FTE East Pilbara 1.6 FTE East Kimberley4 FTE Geraldton 2 FTE Kalgoorlie 2 FTE Esperance6.8 FTE Wheatbelt 2 FTE CUGS 2.6 FTE LGS4.5 Upper SW3 FTE Lower SW
    11. 11. State demographics 500,000 (24%) children aged 0-17yrs (ABS 2006 census) 74% - Metro; 26% - Rural and remote Mental health problem  16.6% of young people (Child Health Survey)  21% Aboriginal children (Aboriginal Child Health Survey, age 12-17) Severe mental disorder  5% young people (Child Health Survey)  11% Aboriginal children (Aboriginal Child Health Survey, age 12-17) 11
    12. 12. State demographics Risk of clinically significant emotional difficulties, age 4-17 (WA Mental Health towards 2020)  15% non-Aboriginal children  24% Aboriginal children 5% children (with mental disorder in clinical range and parental need for help) needed hosp dept psychiatric help (National Survey of Mental Health and Well-being – 2000) Admissions 11/12: 680 (2.7% of severe mental disorder category - WA Child Health Survey) 12
    13. 13. Acute CAMHS Assertive Community Intervention Began with the introduction of ACIT Following on with the Acute Response Team (ART)  Funded by MHC and NPA  Responding to consumer and carer requests for emergency assessments in community, thereby avoiding emergency department attendanceRapid response and comprehensive assessments Identifies, manages and stabilises the most high risk children and adolescents in the community  alternative to inpatient admission  acute high risk phase following discharge
    14. 14. Acute CAMHS Assertive Community Intervention Client Type of service Providing: groupACIT High Admission diversion 8 week intervention risk Intensive outreach Alternative, complementary Under support multidisciplinary model of care to 18s Business hours inpatient treatment. Preventing admission where possibleART Under Emergency Dept Single point of patient flow 18s diversion coordination 7 days a week/24 Telephone consultation for crisis hours a day management & advice In-reach to PMH & all metro emergency departments Community visits in metro area
    15. 15. IN(CON)CEPTION TO BIRTH – Dob 01/08/08 Funding from PMH Gaps in Service Initiative MDT = Psychiatrist, Psychologist, Senior Social Worker, MH Nurses, Ed Liaison Officer, Multi-cultural MH worker (5.5FTE) Training Networking (CAMHS and NGO) and workshops
    16. 16. INFANCY – 1st year ACIT Referrals by Age May 08-April 09 0% 9% 32% 0-4 5-9 10-14 15-19 59% ACIT REFERRALS May 08 - April 0925 22 22 21 2120 18 1815 14 1410 10 9 8 5 3 Nov-08 May-08 Aug-08 Sep-08 Dec-08 Jan-09 Jun-08 Feb-09 Mar-09 Oct-08 Apr-09 Jul-08 0
    17. 17. CHILDHOOD – Model of Care Referral  Daily intake meeting (weekdays), ED and ward referrals Initial assessment  Co-worker model  Contact within 24 hours of referral  Holistic, systemic based assessment approach involving client and relevant family members / guardians or care provider.
    18. 18. CHILDHOOD – Model of Care (cont) Management  Development of crisis plan  Provide family with supportive contacts  Multi-disciplinary assessment and treatment  MDT clinical reviews Discharge / Outcome  8 week intervention  Identification of onward service
    19. 19. CHILDHOOD - change in bed classificationWard 4H (Sep 2009) Assessment bed (minimum of 2 beds daily)  24 hour admission.  Intensive assessment and development of management plan.  Aim to return to community Therapeutic bed (maximum 6 beds)  Need for continued inpatient care  Care coordinator model of care  Goal directed treatment planning
    20. 20. CHILDHOOD - Development of ART Acute Response Team (ART)  Rapid response team to assess overnight admissions to ward 4H, medical wards and ED.  Members: Registrar on duty, PLN, Duty Officer, ACIT clinician, Consultant Psychiatrist.  Optional members: Level 1 and 2 nurses  Linkage with ward 4H and ACIT.  Training environment for junior staff.
    21. 21. CHILDHOOD - Benefits of overnight admission Provide containment of situational crisis Partial resolution of crisis Stabilisation of risk Assessment and case discussion by MDT Allows office hours consultation and liaison Allows transfer to appropriate facility during office hours
    22. 22. CHILDHOOD - ART bed data ART outcome. Sep 09 - Jun10 28% 39% 61% 33% Cont Admit Discharge ACIT Other
    23. 23. CHILDHOOD - ART bed data ART Outcome (FY 10/11) 20% 48% 52% 32% Cont Admit Discharge ACIT Other
    24. 24. ADOLESCENCE Restructure of Metro CAMHS – Feb 2011 ACIT expanded in Jan 2012 (NPA funding for extra 5FTE) Servicing 16-18 age group  Adult emergency departments and  Bentley Adolescent inpatient unit (12 beds, age 12-18) 10.2 FTE  Nursing ; SSW; Specialist Clinical Psychologist; Multicultural worker; OT Case load = 79 (~ 8FTE = 10 clients per FTE) 24
    25. 25. ACIT - Referrals ACIT - Referrals per month (linear regression) Jul08 - Jun124035302520151050 JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Linear (11-12) Linear (10-11) Linear (09-10) Linear (08-09)
    26. 26. ADULTHOOD – Reform of Acute Services Development of ART November 2012  ED diversion program  MHC funding = $1.6M  Assertive community based Ax; 24/7 PLN role; Metro ED Ax; 24 hour bed flow/triage position  13.6 FTE  Nursing; SSW
    27. 27. BENEFITS Many more options for disposal from ED An alternative to admission Reduced length of stay No bed blockage Least restrictive care “Hospital in the home” Closing the gap between Hospital and Community mental health services

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