mental-health-shared-care-for-ethnic-communities by Michael Burville

Mental health shared care for ethnic communities â&#x20AC;&#x201C; a handbook

Brisbane Inner South Division of General Practice June 2001

Mental health shared care for ethnic communities â&#x20AC;&#x201C; a handbook

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Mental health shared care for ethnic communities â&#x20AC;&#x201C; a handbook

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Mental health shared care for ethnic communities â&#x20AC;&#x201C; a handbook

Brisbane Inner South Division of General Practice June 2001

Mental health shared care for ethnic communities â&#x20AC;&#x201C; a handbook

Published by: Brisbane Inner South Division of General Practice PO Box 8004 Woolloongabba Qld 4102 Ph: (07) 3392 2822 Fax: (07) 339 22920 Email: admin@bisdiv.com.au Queensland Transcultural Mental Health Centre Princess Alexandra Hospital Ipswich Rd Woolloongabba Qld 4102 Ph: (07) 3240 2833 Fax: (07) 3240 2282 Email:Rita_Prasad-Ildes@health.qld.gov.au

ÂŠ 2001 Brisbane Inner South Division of General Practice, Queensland Transcultural Mental Health Centre, Department of Health and Aged Care, Australian Transcultural Mental Health Network. This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source and no commercial usage or sale. Reproduction for purposes other than those indicated above requires permission from the Brisbane Inner South Division of General Practice and the Qld Transcultural Mental Health Centre. Contact details for these organisations are listed above. Additional copies of the handbook are available from the ATMHN. Tel: 02 98403333, Fax: 02 98403338, Email: atmhn@wsahs.nsw.gov.au This handbook was funded by the Commonwealth Department of Health and Aged Care under the National Mental Health Strategy through the Australian Transcultural Mental Health Network and Queensland Health, through the Queensland Transcultural Mental Health Centre. ISBN 0-9579120-0-5 Written and designed by Marina Chand, saima@comcen.com.au

Mental health shared care for ethnic communities â&#x20AC;&#x201C; a handbook

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Table of contents

INTRODUCTION………..…….…………….7 PART ONE – ISSUES IN ETHNIC MENTAL HEALTH SHARED CARE

PART TWO – SETTING UP ETHNIC MENTAL HEALTH SHARED CARE

Why use shared care?………..………10

Components of ethnic shared care………………………………….………..24

Ethnic communities & mental health……………………………..…………10 General practice & ethnic mental health………..…………………..………….14 Shared care with ethnic communities………….…………………..16

Developing relationships, systems & protocols……………………..………….27 Care planning processes……...……..30 Maintaining shared care………….….31 Evaluating the program…….………...32

Lessons learned………………………...19 REFERENCES …..………………………..37 Evaluation………………………………….21 APPENDICES – Protocols used in Brisbane inner south project 1 – GP resources summary…….…..37 2 – Fax request form ……………......38 3 – GP quick reference guide ….….39 3 – GP resource guide ……….……...40

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List of tables: Table 1 – Factors relating to under-recognition of mental disorders Table 2 – The GP role in ethnic mental health shared care Table 3 – Shared care arrangements & resources in the Brisbane inner south shared care project Table 4 – Strategies and considerations for program sustainability Table 5 – Evaluation strategies in the Brisbane inner south project from the perspective of three participant groups Table 6 – Evaluation framework for program effectiveness in the Brisbane inner south project

p14 p15 p25 p31 p32 p34

List of figures: Figure 1 – People of NESB with mental health problems in Australia Figure 2 – Ethnic mental health shared care program framework

p13 p24

List of boxes: Box 1 – The Brisbane inner south mental health shared care project for ethnic communities Box 3 – Accessing and using the Translating and Interpreting Service

Mental health shared care for ethnic communities – a handbook

p 8 p29

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INTRODUCTION This handbook contains practical strategies for the establishment of ethnic mental health shared care programs and arrangements, and offers insights into the issues affecting shared care for ethnic communities. Some of the issues that affect shared care service delivery to people of nonEnglish speaking background (NESB) are similar to those for the community at large, however there are also distinct issues involved. The focus of this handbook is on these distinct issues.

The aim of the project was to enhance general practitioners’ (GPs) skills and knowledge in an early intervention model where people of NESB exhibiting early signs and symptoms of mental disorder could be identified, assessed and treated.

The general purpose of the handbook is to assist those planning to set up ethnic mental health shared care programs. The handbook guides the reader through the main issues that should be considered before setting up an ethnic shared care program and then provides practical information that may assist the implementation phase. More specifically the purpose of the handbook is to assist divisions of general practice and others to:

The project report of the ‘Brisbane inner south project’ is available as an optional extra for those interested and is a valuable companion document, but is not necessary, to use and understand this handbook.

The project provided resources and support to GPs with assessment and diagnosis and ongoing support of their patients in a general practice setting. The project had a strong evaluation focus.

This handbook is divided into two sections: 1. Section one outlines pertinent issues in shared care for ethnic communities

1. Plan and implement programs in 2. Section two is a how-to manual for setting up shared care for ethnic shared-care that can meet the communities specific needs of clients of NESB; 2. Incorporate the needs of clients of NESB into existing shared care The handbook may be particularly useful to the following who are interested in setting programs. up ethnic shared care programs and arrangements: Much of the information in the handbook is based on experience gained • Divisions of general practice from an ethnic mental health shared • Multicultural health organisations care demonstration project in • Mental health organisations and Brisbane. This project piloted a shared services care approach between the Brisbane Inner South Division of General Practice and key services working with people of NESB with mental disorders. Mental health shared care for ethnic communities – a handbook

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Introduction

The Brisbane Inner South Mental Health Shared Care Project for Ethnic Communities Who was involved? The Brisbane Inner South Division of General Practice, Qld Transcultural Mental Health Centre, West End and Coorparoo Mental Health Services, Qld Program of Assistance to Survivors of Torture and Trauma, the Ethnic Mental Health Program and the Qld Divisions of General Practice. What did the project do? The project established and piloted a shared care model for people of NESB exhibiting the early signs and symptoms of a mental disorder. How was shared care established? The project formed a reference group with representatives from the agencies participating in shared care and implemented the following strategies:

• Undertook a comprehensive literature review and developed an evaluation plan

• Recruited 15 GPs with an interest in participating in shared care • Developed and implemented a Transcultural Mental Health Training Course for GPs • Introduced systems to facilitate and formalise shared care through the development of a GP handbook consisting of referral guidelines, service request fax forms, interpreter booking forms, Enhanced Primary Care Items information and key contacts in mental health services. • Undertook process and impact evaluation, pre and post training evaluation, and a cost analysis. How did the project involve consumers? The project involved consumers in the project development phase through a consumer focus group and interviewed consumers at the conclusion phase to assess impact and satisfaction. Project information and data collection information was translation in six key languages and passed on to consumers through their GP.

What did the project find out?

The GP sample was small and therefore results could not be generalised. However, the project found that a training course comprising both GPs and service providers was very important not only for information dissemination but also relationship building. Although the response to shared care arrangements from the project GPs was slow and gradual, the evaluation revealed that they offered significantly more options to their patients diagnosed with depression and/or anxiety compared to GPs who had not received the training. Some factors in the slow uptake to shared care by GPs was identified by GPs as being due to patient resistance to other service providers, lack of availability of culturally appropriate resources, lack of time, in house barriers in their current practice environment, hesitation to get too involved in fixed term projects, and difficulties in attending meetings. Implications of the project The project recommended that ethnic shared care programs be linked with mainstream shared care programs in order to maximise impact and ensure sustainability. It was clear from feedback from GPs and service providers that smaller projects are not well regarded. Training was a key factor to engage GPs with service providers and time needs to be build in for discussion and relationship development. Systems such as fax forms for easy contact and referral, guidelines on who to contact in what instance, contacts for direct access to staff in mental health services are all important components of a shared care project. The project found that the prevalence of depression and anxiety for people of nonEnglish speaking background was similar to that of the general population but found that GPs who saw considerable numbers of patients from refugee backgrounds reported double the prevalence rates. It is therefore important that shared care programs include specific strategies to include bilingual GPs and ethnic health services.

Box 1 – The Brisbane inner south mental health shared care project for ethnic communities

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Part one â&#x20AC;&#x201C; issues in ethnic mental health shared care

Mental health shared care for ethnic communities â&#x20AC;&#x201C; a handbook

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WHY USE SHARED CARE? General practitioners and mental health s e rvi ces have worked together informally for many years, sharing the treatment and care of people with mental health problems. However, this has not necessarily been routine or systematised as a treatment and care approach.

“I found having a psychiatrist coming out to my surgery a great help, it was a fantastic resource…” - GP in the Brisbane inner Shared care typically tends to focus on south project the development of systems and protocols to facilitate communication between the program participants “I had depression before through structured agreements about coming here, now my respective roles, responsibilities and situation has worsened. I expectations regarding patient care. In recommend the support I Australia, the majority of mental health have received, I don’t shared care has been in the context of know if I could manage on discharging stable patients from mental my own”. - patient in Brisbane inner health services to the care of a general practitioner. south project

However, there are many different models of shared care. Some of these are outlined below (SERU 1997):

“We really want GPs to be part of the treatment team, we will set up case • conference times to suit the GP, we just need more GPs that we can w or k w i th! We acknowledge that it’s very • difficult to find the time that suits both the GP and the case worker”. - service provider in the Brisbane inner south • project

• •

up-skilling and educating program participants in mental health assessment, diagnosis, treatment and management; e n han c i n g and formalising communication, information and r e ferr al pathways betwee n participating services, particularly between GPs and services; providing a mental health liaison officer to coordinate communication, facilitate access and transfer between services and general support; attachment of mental health workers to GPs; and attachment of GPs to mental health services.

These programs have however not been specifically designed to meet the needs of NESB clients. Mihalopolous et al (1999) identified the need to further pilot and evaluate shared care models before conclusions could be made about optimum shared care models for ethnic communities, given the paucity of information about the mental health outcomes of NESB clients within numerous shared care programs operating throughout Australia. The Brisbane inner south mental health shared care project, on which this handbook is based, was one such project. The Brisbane inner south project was a combination of models one and two outlined above. The focus was on up-skilling GPs to enhance their skills to detect and respond to NESB patients exhibiting the early signs and symptoms of mental illness. The secondary focus was to enhance and formalise communication and referral pathways between the program participants. The evaluation of the program revealed that: •

•

patients generally had positive feedback about their GP and mental health service providers; service providers perceived shared care as a priority despite not receiving as many referrals from GPs as anticipated and were still seeking more ‘mental health friendly’ GPs; and GPs who actively participated in shared care found it a positive experience but it was difficult to involve all GPs fully.

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ETHNIC COMMUNITIES & MENTAL HEALTH SERVICES This section presents information about the prevalence of mental illness among people of NESB in Australia and their use of mental health services. The literature does not have consistent findings of mental disorder rates within NESB communities in Australia. This may be due to several factors. Firstly, measurement of the prevalence of mental disorders in people of NESB is fraught with difficulties because different cultural groups may express psychological symptoms in different ways, and research instruments are often not reliable nor cross-culturally valid. Secondly, people who do not speak English are often excluded from quantitative studies such as the National Survey of Mental Health and Wellbeing. Minas (2000) pointed out that there is a substantial and often confusing literature on the prevalence of mental illness in indigenous and immigrant populations. The results of prevalence studies vary widely according to the disorder studied, ethnic group and location of the study. In summary, in some studies prevalence rates for a particular ethnic group are higher than the host population, in others the rate is lower and in others the rate is the same. The National Survey of Mental Health and Wellbeing (1999) reported limited information on the mental health of people of NESB, but found that the prevalence of mental disorders was slightly lower in people born in nonEnglish speaking countries (12.5 percent in males compared to 18.4

percent of Australian born males and 16.9 percent for females compared to 18.7 percent of Australian born females). The national survey concluded that these figures probably reflected a ‘healthy migrant effect’ persons who do not have mental disorders are more likely to be interested in migration, and probably more likely to be accepted as immigrants. Refugees are singled out in the literature as having higher rates of long term medical an psychological conditions than other migrants, tend to report a poorer state of well being and visit health care providers more frequently (Lehn 1997). Refugee claimants have been documented as having even worse mental health status as a group separate from those whose refugee status has already been determined (Silove & Steele 1998). Minas commented that it is not immigrant status, in itself, that is associated with either a high or low prevalence of mental disorder but that there are many factors that are part of the experience of some immigrants (such as pre-migration experiences of trauma and disrupted families) that may be associated with increased vulnerability (2000). Other postmigration experiences that may i n c r e a s e v u l n e r a b i l i ty i n cl u d e unemployment, lack of skill recognition, social isolation, language barriers and lowered social status. Service access to appropriate mental health care is particularly pertinent for NESB people. Mihalopoulos et al

Mental health shared care for ethnic communities – a handbook

“I don’t feel productive any more. The system forces people to be unproductive…” “...I’m grumpy, I’m isolated, not going out, I distrust people…” “My children have goals I’m not financially able to give them. I have no plans for the future.” “The impossibility to adjust in this new society/ country – I feel disabled!” “Put more effort into treating people like human beings. I was happy with the student, less with the psychiatrist.” - patients in the Brisbane inner south project

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“I find that when working with new arrivals, like people from the Horn of Africa or the Middle East there are so few culturally appropriate resources around that it is very difficult…” - GP in the Brisbane inner south project

Ethnic communities & mental health services

(1999) reported several other Australian studies that suggest that people of NESB are at least as likely to visit a GP for a consultation for mental health problems, compared with their Australian-born counterparts. In a British study, Schurman et al (1984 in Mihalopoulos et al 1999) found that people of NESB were more likely to attend GPs for mental health problems than their English-born counterparts, but in Australia studies show that NESB people use their GPs as often as other patients. However, it has been established that NESB people prefer GPs who share their language and cultural background. Despite this, several Australian studies have confirmed that NESB people are less likely to receive treatment for their mental health problems and have their mental disorders diagnosed later in onset (McDonald and Steele 1997; Finlay-Jones and Burvill 1978 and

Lloyd 1993 in Mihalopoulos et al 1999). In Australia it has also been established that people of NESB are less likely to receive treatment and care from specialist mental health services in both hospital and community settings (McDonald and S t e e l e 1 9 9 7; S tol k 1 9 9 6 i n Mihalopoulos et al 1999). Furthermore, once they do gain access to such services, people of NESB stay longer in hospital care, have higher or equal rates of involuntary admission but significantly lower rates of voluntary admission, have shorter faceto-face contacts in community settings, and are less likely to receive talking therapies than their English speaking counterparts (McDonald and Steele 1997; Stolk 1996, Trauer 1995, Lloyd 1993, Balabil and Dolan 1992 in Mihalopoulos et al 1999).

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Ethnic communities & mental health services

People who do not speak English are often excluded from quantitative studies such as the National Survey of Mental Health and Wellbeing.

Refugees have a higher rate of long term medical and psychological conditions than other migrants, and report a poorer state of well being and visit health care providers more frequently.

Prefer GPs who share their language and cultural background.

Are at least as likely to visit a GP for a consultation for mental health problems, as their Australian-born counterparts.

Are less likely to receive treatment for their mental health problems and have their mental disorders diagnosed later in onset.

Once they do gain access to mental health services, stay longer in hospital care, have higher or equal rates of involuntary admission but significantly lower rates of voluntary admission.

Refugee claimants have even worse mental health status as a group separate from those whose refugee status has already been determined.

People of NESB with mental h eal th problems in Australiaâ&#x20AC;Ś

Are less likely to receive talking therapies than their English speaking counterparts.

Are less likely to receive treatment and care from specialist mental health services in both hospital and community settings.

Have shorter face-to-face contacts in community settings.

Fig 1 â&#x20AC;&#x201C; People of NESB with mental health problems in Australia

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GENERAL PRACTICE & ETHNIC MENTAL HEALTH

“It would be good to provide more support to GPs who speak other languages. Apart from the fact that we can save money as we don’t need interpreters, we are a very important resource with the communities we work with and sometimes we are isolated. A project like this is excellent, for me anyway, it was a great opportunity”. - GP in the Brisbane inner south project “There are no people here

with my condition. My doctor said my condition (diagnosis) is not in the book.” - patient in the Brisbane inner south project

The pathway to mental health care for people of NESB begins with the GP. Despite their reluctance to seek assistance from mental health services, NESB people do visit their GP for physical and mental health issues (Mihalopoulos et al 1999). People of NESB generally have a preference for a GP who shares their cultural and linguistic background. However, it has been documented that GPs tend to under-recognise

mental disorders within people of NESB and consequently diagnosis occurs later in onset of the illness. It is important that GPs have an awareness of the factors that contribute to the under-recognition of mental disorders in NESB people. According to Hickie (1999) these factors relate to the patient, doctor and service:

Factors relating to under-recognition of mental disorders: Patient related factors

• tendency to present with somatic rather than psychological complaints, • the co-occurrence of medical and psychological problems, • stigma associated with psychological diagnosis and treatments Patients of NESB: all the above factors are applicable with very high levels of stigma in some ethnic communities; differences in expression of psychological distress and mental illness symptoms across cultural groups; and absence of notion of ‘mental health’ in some cultural groups.

Doctor related factors

• • • • •

Insufficient interview and diagnostic skills, Insufficient undergraduate and postgraduate training, Inadequate time devoted to diagnostic assessment, Lack of acquisition of new knowledge relevant to treatments, Insufficient remuneration for long consultations

When treating patients of NESB: all the above factors are applicable and in addition a lack of awareness of the stages of settlement; lack of training in cross-cultural communication; and lack of cross-cultural clinical skills. Service related factors

• insufficient remuneration for psychological interventions, • insufficient support from specialist public and private mental health services, • inadequate access to non-medical mental health professionals Services for patients of NESB: all the above factors are applicable and in addition, a lack of standardised processes for booking and using professional interpreters; and insufficient flexibility to cater for longer consultations that are required for the use of interpreters.

Table 1: Factors relating to under-recognition of mental disorders (adapted from Hickie 1999)

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General practice & ethnic mental health

The factors outlined in Table 1 are further complicated by cross-cultural communication and poor English l an g u age sk ill s by p atie n ts. Recognition of the mental disorder by the GP will vary according to the patient’s ethnicity, cultural influences on clinical presentation and the explanatory model of his/her condition (Kleinman 1978). The GP has a particularly pivotal role in the assessment, diagnosis, treatment and management of Aspect of mental health care

GP role

Detection & diagnosis

• Essential for provision of primary

Prescribing

mental illness in people of NESB. With the growth of prevention and promotion strategies under the National Mental Health Strategy, there is also an expectation that GPs be involved in the prevention of mental illness and the promotion of mental health. The table below outlines the special role of GPs in relation to mental health care and more specifically, the additional factors that need to be considered when working with people of NESB (adapted from SERU 1997): Additional factors to consider with NESB patients

• GPs are often the only service sought out health care • Rates are lower than the community at • Rates are variable amongst GPs for large complex reasons • Diagnosis often requires cultural input • Often the first contact point • Tendency to present somatic complaints • The need to use professional interpreters when there is a language barrier • Informed prescribing • Readily accessible advice • Regular reviews of medication

Non• Case management or coordination pharmacologi- • Counselling cal treatment • Support & advocacy • Information provision

• Awareness of ethno-psychopharmacology • Extra care with instructions and advice about medications

• Awareness of ethnic support agencies • Awareness of multicultural counselling services and specialist services • Multilingual information

Monitor of physical health

• Treatment and care of physical

Case manager

• Liaison with other service providers • Awareness of ethnic and other specialist services • Case planning • Case review • Receive patient feedback

Prevention

• Collaboration with self-help groups • Prevention & promotion activities • Receive patient feedback

symptoms • Receive patient feedback

• Awareness of tendency by NESB patients to only present with somatic complaints

• Partnerships with ethnic groups and ethnic health workers

Table 2: The GP role in ethnic mental health shared care

Mental health shared care for ethnic communities – a handbook

The role of the GP in mental health care for people of NESB is multidimensional and pivotal. The GP can easily be the primary service provider given NESB people’s reluctance to use specialist mental health services and their preference to seek assistance from their GP. GPs should be made aware of the opportunities that are now available for them to be care coordinators through the Enhanced Primary Care (EPC) items for care planning and case conferences. Part Two of this handbook has further information .

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SHARED CARE with ethnic communities Shared care programs for ethnic communities have many features in common with shared care programs for the community at large but also have a number of unique features that are explored in this section. Working with patients of NESB means GPs and other program participants will: • Encounter •

•

different world views Encounter different explanatory models for mental illness and symptoms Encounter different values and approaches to problem solving Need to consider working with nontraditional partners such as spiritual leaders, alternative health practitioners and ethnic voluntary groups. Need to consider strategies to facilitate patient input/ feedback on services received.

These are state-wide services in states such as Queensland and can be accessed on a 1800 number. However, in areas where transcultural clinical consultation services are not available, the following may comprise an equally important component of an Like other shared care programs, ethnic mental health shared care ethnic shared care programs also program: effect systemic change by changing the Welfare workers of NESB • way service providers work with each GPs of NESB other. However, the key difference is • Allied health workers of NESB in the actual operation of the • Multicultural settlement or program - in the incorporation of • community workers ethnic groups and workers and Voluntary multicultural groups • language services. The special attention that bilingual GPs and ethnic These workers and groups could workers require are also pertinent to provide culturally-related information the success of an ethnic shared care and in some cases, act as a cultural program. broker between the GP and the patient. However, a word of caution Transcultural clinical consultations about confidentiality must be heeded as voluntary groups are generally not One of the challenges for GPs can be bound by a code of ethics nor work to grasp and interpret their NESB under policies of confidentiality. patient’s cultural context, i.e. their belief system, cultural-specific Cross-cultural communication expression of symptoms, norms for behaviour and general explanatory Every consultation with a patient model. These are crucial factors for involves a cross-cultural experience the identification of patients with a for the GP. Even if the patient is possible mental disorder. seemingly from the same cultural background as the GP, it is likely that GPs cannot be expected to know about they come from a different social every culture and ethnic group that status, geographical area or family may present in their surgery. Hence, background. According to Fitzgerald access to transcultural clinical (1992) in every clinical interaction consultations form an essential there are at least three cultures and component of a shared care program medical systems involved: for ethnic communities. Some states in Australia have transcultural mental health centres that provide precisely such a service.

– the personal or familial culture of the provider (GP) – the culture of the client or patient

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What is different about ethnic shared care

– the culture of the primary medical system And when the patient comes from a NESB, there is a fourth culture: – the traditional medical culture The GP may make assumptions about the patient’s behaviour or belief systems based on what makes sense in his/her own culture. With patients from non-English speaking countries, GPs may make even greater assumptions about their patients and the likelihood to make errors in judgement and understanding increases tremendously. It is also less likely that the GP’s values, beliefs or attitudes are shared by their NESB patient. Ethnic mental health shared care programs should incorporate a professional development component f or GPs about cross-cultural communication and pertinent issues affecting health care in a culturally diverse society. It would be useful to address, at the very least, the following issues: •

c u l t u r a l s t e r e o t y pin g : the categorisation of people and experiences. Unfortunately they are inadequate as sources of detailed information about an i n div idual patient from a particular background.

•

attribution: the assumptions that are made about the reasons a person is behaving in a particular way, based on what would make sense in the GP’s own culture.

•

eliciting explanatory models: the way a patient understands his/ her life, problems, relationships and illness, including spiritual, political, social and cultural beliefs. Western medicine has its own explanatory model that may not be acceptable to particular cultures. language issues: cross-cultural communication involves more than having a common language but the need for professional interpreters should be emphasised in any training.

Language related issues An important consideration in an ethnic mental health shared care program is that of language services. Unfortunately, many GPs still don’t routinely use professional interpreters when there is a clear need to use one. GPs also need to be discouraged from using relatives as interpreters and should be made aware of the legal implications of doing so. The use of professional interpreters will need to be addressed both in the form of professional development, but also in the form of shared care protocols, forms and processes. Conversely, GPs also need to be prepared for some of the difficulties and challenges surrounding the use of interpreters. If the use of professional interpreters is integrated into shared care program arrangements, it is more likely that they will be used. It will also be important to make GPs aware

Mental health shared care for ethnic communities – a handbook

For me the biggest plus out of this project has been working with interpreters. Before this I sort of knew that it was around but not sure how to go about doing it.” - GP in Brisbane inner south project “We have had the situation where we have booked an interpreter for 2 hrs and booked 3 patients from that language group and then we have a no show for 3 patients so the interpreter and GP is standing around with no patient. We know that for new arrivals there is trauma and people are disorganised as they have so much to deal with but from our point of view it is such as waste of precious resources. We only have access to interpreters from a very limited quota and you feel very bad when you know this resource is wasted due to no shows.” - GP in Brisbane inner south project

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General practice & ethnic mental health

how interpreters can be booked and provide the correct information about the cost of professional interpreters. Part two contains more detailed information about accessing and using professional interpreters.

“... I like to talk but I have no friends, I lost trust…” - patient in the Brisbane inner south project “They are doing what they are told. They go according to the book. It’s impossible to talk to them, they don’t listen. They use a language I don’t understand”. - patient in Brisbane inner south project

Ethnic shared care programs will also need to translate written information about the program into the high demand community languages. This has a cost impact on the overall program budget.

Working with ethnic services and groups

workers,

An ethnic shared care program will most often involve working with a range of ethnic workers and groups. Most metropolitan areas have ethnic welfare and even ethnic mental health workers. These workers are important partners in ethnic mental health shared care as they can

provide vital information about ethnic social support options and may even u n d e r t a ke i n d iv i d u a l suppor t themselves. Capital cities generally also have specialist refugee health services such as counselling services for survivors of torture and trauma. Once again, these organisations constitute important partners in the program or they may even be program participants. Ethnic social or cultural groups may constitute important social support options for clients of the ethnic mental health shared care program. It will be important for program staff to fully brief all the participants about such groups and organisations and/ or provide information resources about finding and accessing such groups.

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LESSONS LEARNED This section is based on the lessons learned about ethnic mental health shared care in the Brisbane inner south project. Given that the Brisbane inner south project was a demonstration project, there were many issues both foreseen and unforeseen that impacted on the project. These are presented in this section. Limitations of ethnic shared care The Brisbane inner south project was a stand-alone program that was not attached to a larger or ‘mainstream’ shared care program. Throughout the project period it became more and more clear that the ethnic shared care project was regarded as a (small) competitor to other shared care projects by some services. Given the popularity of shared care as an approach to treatment and care in the mental health sector, several other shared care programs were operating in the same geographical area as the ethnic shared care project. Some of these shared care programs were better resourced than the ethnic program and were even in the position of providing financial resources to mental health services. This made it difficult for the ethnic program to ‘compete’ and had to solely rely on the goodwill of the participants. Ethnic shared care should be regarded as one stage in the implementation of an overall, culturally inclusive, shared care program. Because cultural diversity issues can be challenging to incorporate into a large program, the

special processes required are best developed in an exclusively ethnic shared care program that eventually will be integrated into a ‘mainstream’ shared care program. The ethnic shared care program should however be resourced in the same way as the overall program so that it is not marginalised. Once the ethnic shared care program is running smoothly it can be systematically integrated into the overall shared care program, paying special attention to the preservation of processes that address the complex issues of cultural diversity amongst patients and practitioners. GP recruitment The GP participants of any shared care program form an integral part of the program and therefore special attention should go towards the recruitment of GPs. In the Brisbane inner south project all the GP participants were fully briefed about the objectives and limitations of the project, yet a number of misconceptions remained, particularly about GPs needing to give up case coordination to other services. Other GPs thought they could use the shared care program to refer mental health patients on. It is also crucial to the success of the program that a good sample of bilingual GPs are involved. It is highly likely that the very GPs required, will have a relatively low profile with their local division of general practice, as some bilingual GPs have generally not been as actively involved in Division

Mental health shared care for ethnic communities – a handbook

“...a good project, I did not use it the way I should have…” - GP in the Brisbane inner south project “for us partnerships with GPs is a priority, in fact it is in our strategic plan…” - service provider in the Brisbane inner south project

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Lessons learned

programs.

“ I am also aware that there are financial issues to working together. We have had the experience of co-locating with a number of GPs and this was discontinued as for the GPs it was no longer financially viable. They told us they could make three times as much money in the same time by not seeing our mental health patients.” - service provider in the Brisbane inner south project “I enjoyed talking to other GPs, training was good, it opened my eyes.” - GP in the Brisbane inner south project

Ethnic community contacts and ethnic community health workers are a valuable source of information about popular bilingual GPs that many people in a particular community tend to use. It is important that these GPs be approached and invited into the shared care program. It is also recommended that the GP participants should comprise a small number of highly regarded GPs who are well known advocates of shared care programs and/or ethnic health issues. These GPs will champion the issue of ethnic health and display a great deal of commitment to the program. They may also motivate other GPs to accept the challenges of working in this area. Finally, the reluctance by GPs to use long consultations for mental health issues remains a difficult issue. Many GPs are under pressure to work within short appointment times and therefore cannot adequately deal with mental health issues that may require more time. This may be further exacerbated by the use of interpreters which place further time demands on GPs. This issue may also need to be addressed from the outset, during GP recruitment, as the reluctance to take the time necessary for a mental health consultation, may reduce the quality of care able to be offered by GPs. Training and up-skilling The training and up-skilling needs of GPs in relation to mental health and

transcultural clinical issues should not be underestimated. It is highly recommended that training needs be overestimated rather than underestimated! Training is also ideally conducted on an ongoing basis, rather than at the outset of the program. In this way, GPs and other participants can bring real practice issues to their training. There is also a real benefit in including other participants such as mental health service providers in the GP training. Their participation can facilitate the building of positive working relationships that are necessary in shared care programs. In the Brisbane inner south project the issue of motivating GPs to attend training was constantly grappled with. To date no conclusions have been drawn about this issue despite numerous attempts to dialogue with GPs about their low attendance at case discussions and ongoing training opportunities. It was observed that visiting GPs at their clinics and working on a one-to-one basis was the most effective way to engage with them but this was difficult to provide within the resource constraints of the project. The following strategies were used to encourage greater GP participation: • Six weekly short case discussion groups. • Motivational sessions with GP speakers

who were strong advocates of shared care. • Discussion group about dealing with patient reluctance to be referred on. • An offer to facilitate an actual case conference including case planning, support and follow-up.

Mental health shared care for ethnic communities – a handbook

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EVALUATION Evaluation forms an important component of a shared care program. Program impact and outcome evaluation is often a requirement of funding and may form the basis of the evaluation framework. However, as De Bruyn (1994) points out, there are a number of unique features of the mental health field that make outcome evaluation more difficult than in the medical field: • Diversity of theoretical constructs

• •

•

and therapeutic approaches to mental health and mental illness Intangible qualities of mental health practitioners Difficulties for health care teams to come to a consensus on diagnosis and treatment M i x o f c o n tri bu ting factors (treatment and non treatment) to outcomes during a period of care (i.e. confounding variables that may ‘contaminate’ evaluation findings) Chronicity of mental illness and difficulties in tracking patients and assessing care through multiple types of services and settings Difficulties in developing reliable and valid tests of the various aspects of quality care and quality of outcomes And lack of identification of data needed and appropriate information systems.

In the literature, the five most common and consistent dimensions of outcome evaluation, which have appeared in the mental health fi eld include: symptomatology, patient functioning, quality of life, patient satisfaction and

costs (health care utilisation) (De Bruyn 1994). It is suggested that a realistic and practical evaluation framework be developed, with the above mentioned complexities in mind. (Part two of this handbook provides a practical guide for evaluation.) There should also be a focus on consumer outcomes and gains in their quality of life, as a direct result of the program. De Bruyn (1994) has identified the following measures and operations used by researchers, administrators, and clinicians over the past two decades to evaluate approaches, programs, and outcomes in mental health care: • Quality assurance programs and • • • • • •

total quality management Utilization review Accreditation and certification of mental health facilities Measurement of quality of life Measurement of outcome Assessment of continuum of care, and Isolation of factors that contribute to outcomes of care and quality of life

Whatever approach or method is employed, it is important to remember that program participants will be relied upon to obtain and record a significant proportion of the data. It is important that the methods and data chosen are feasible and accessible for those required to be involved. In the Brisbane inner south project, an

Mental health shared care for ethnic communities – a handbook

“The data collection was not explained adequately, some data was useless and it was hard to collect data from so many people.” - GP in the Brisbane inner south project

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Evaluation

attempt was made to conduct a prospective evaluation to determine:

and time-line, a cost analysis was done.

•

The magnitude of the problem addressed by the intervention (literature review) Whether the intervention worked ac c ording to the specified objectives of the project (program effectiveness evaluation). An indication of the cost of management of depression/ anxiety by a GP from the perspective of cost to the government (cost analysis)

The Canadian Journal of Psychiatry (1998) stated that a problem with economic evaluations is that many of the costs and benefits of treatments are extremely difficult to quantify economically and in addition, difficult to put a dollar value on what often may be the most important benefit of an effective intervention (i.e. increased satisfaction, wellbeing, self esteem and personal happiness in the recipient).

The feasibility of conducting an economic evaluation was explored. However, due to the unavailability of data from a comparison group and other constraints in the project budget

Economic evaluations are certainly beneficial to do but particular conditions and resources are required and this must be borne in mind from the outset.

•

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Part two â&#x20AC;&#x201C; setting up ethnic mental health shared care

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COMPONENTS OF ETHNIC SHARED CARE This section presents an ideal program framework for ethnic shared care and explores the key components of ethnic shared care. An overall program framework In developing the shared care program, it is important to consider the relationship of the program to other (mainstream) shared care programs. As discussed in the ‘Lessons Learned’ section, the experiences of the Brisbane inner south project led to the conclusion that ethnic shared care programs should have strong links with

a mainstream program, with a view to fully integrating the two. The ethnic program allows for the development of transcultural expertise that can be transferred into a mainstream program at a point when the expertise is fully developed and strong enough to withstand the pressures of a mainstream program. The mainstream program however, would be expected to incorporate transcultural practices and protocols into overall operations to facilitate the preservation of this expertise. This overall program framework can be conceptualised as follows:

STEP 1

Ethnic shared care program set up concurrently & in conjunction with mainstream shared care program. Specialist expertise is developed.

Mainstream shared care program set up in conjunction with ethnic shared care program.

STEP 2 Ethnic shared care program once fully operational, is integrated into mainstream program, without loss of transcultural practices.

Mainstream shared care program integrates ethnic component into overall operations, including transcultural practices/ processes for patients of NESB.

STEP 3 Culturally inclusive shared care program.

Fig 2: Ethnic mental health shared care program framework Mental health shared care for ethnic communities – a handbook

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Components of ethnic shared care

The separate development of the ethnic component of the shared care program is important for the development of expertise and experience. Ethnic shared care is extremely complex and warrants special attention in the setting up phase of a shared care program. However, once developed, this expertise can be shared through the integration of the ethnic shared care program with the mainstream shared care program.

shared care project and the resources made available to participating GPs. In the Brisbane inner south project, the following participated in the ethnic shared care program: •

• • •

Components of ethnic shared care •

The ‘components’ of shared care refers not only to the program participants but also to the arrangements and resources developed by the program. The chart below provides a snap-shot of the shared care arrangements that were put in place in the Brisbane

•

selected GPs from the Brisbane Inner South and Southside Central Divisions of General Practice selected adult mental health services Ethnic Mental Health Program (NGO) Queensland Transcultural Mental Health Centre (Queensland Health) Queensland Program of Assistance to Survivors of Torture and Trauma (NGO) Queensland Divisions of General Practice, Mental Health Support Strategy (NGO) Patients of NESB from different communities.

Phase of care Shared care arrangements put in place

Resources made available to GPs

Identification, Clinical consultation assessment & diagnosis Transcultural clinical consultation

GPs could request consultations with the following: 1 Psychiatrist 2 Transcultural clinical consultation service, Queensland Transcultural Mental Health Centre 3 Joint assessment with workers from Ethnic Mental Health Program or Queensland Program of Assistance to Survivors of Torture & Trauma

Management of patient care

Access to bilingual mental health staff brokered by the Queensland Transcultural Mental Health Centre

Short-term clinical intervention

Joint case-management with Ethnic Mental Health Program and Queensland Program of Assistance to Survivors of Torture & Trauma and adult mental health services Table 3: Shared care arrangements and resources in the Brisbane inner south project Mental health shared care for ethnic communities – a handbook

“The role of the GP is very ‘heavy’ when it comes to looking after people with mental health problems. For me the project was great, in fact it was uplifting to be supported, it assured me a lot that there are others that I can work with, that we can work together”. - GP in the Brisbane inner south project

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Components of ethnic shared care

At the very least, an ethnic shared care program should aim to involve: •

• •

In areas where transcultural clinical consultation services are not available, the following may comprise an equally important component of an ethnic mental health shared care program: • welfare or community

workers of NESB

• allied health workers of

NESB • multicultural settlement or community workers • voluntary multicultural groups

Selected GPs interested in the program and who already see NESB patients/are willing to see NESB patients with mental health problems Mental health service/clinic Ethnic mental health or welfare workers, or even ethnic voluntary organisations if these are not available in the local area.

GPs – Since people of NESB prefer to see a bilingual or bicultural GP, it is important to consider the involvement of bilingual GPs. Furthermore, monolingual GPs working in areas with a high concentration of NESB people, may also have special skills and experience to offer the shared care program. Regardless of the linguistic background of participating GPs, it is essential that they have an interest in the program, an interest in NESB mental health issues and the time to allocate to extra tasks that may be required such as discussion groups or additional paperwork. In the Brisbane inner south project it also became apparent that the GPs who demonstrated high levels of commitment to the program became important role models for the other GPs. It is therefore suggested that GPs who are well known advocates of shared care are actively recruited to participate in the ethnic shared care program. The influence of peer education and positive role modelling by people who GPs respect, should not be underestimated. (Mazza 2000). Mental health services – These important services provide the mental health expertise to a shared care program. Most public mental health

services are restricted by geographical boundaries and also severity of mental illness and these issues should be considered from the outset. Many shared care programs work across a number of geographical areas and therefore involve more than one mental health service or clinic. Regional areas may not have a mental health clinic, but a visiting team of mental health workers or a part-time clinic. Som e me n tal he alth services experience high rates of staff turn-over. For this reason it is important that the involvement of and communication with mental health workers is organised in a systemic way, for example through existing whole of agency processes such as team meetings or intake meetings. Mental health workers involved in the shared care program may need the support of shared care program staff to effect organisational change to institute processes such as changes in paperwork, referral protocols and intake protocols. Team leaders and managers should be involved wherever possible. Ethnic mental health, welfare or community organisations – These vital groups contribute the important cultural input into the ethnic shared care program. They often have excellent links with ethnic communities, have ‘inside’ knowledge about community structure and networks, and have specialist knowledge about cross-cultural communication and practice issues. Depending on the location in Australia, the sophistication and range of ethnic resources available will vary. State transcultural mental health centres or psychiatry units are an excellent starting point.

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DEVELOPING RELATIONSHIPS, SYSTEMS & PROTOCOLS The foundation of shared care is the relationships developed between service providers participating in the program. Service providers may already have an informal working relationship but the aim of the shared care program is to formalise and systematise working relationships and processes between service providers. This chapter explores the important steps in this process. Identifying and engaging GPs In an ethnic shared care program, it is likely that the participating GPs will either be bilingual themselves, or work in geographical areas with high concentrations of people of NESB. It may be easy to readily identify the key GPs that could be approached to participate in the ethnic shared care program because they are well known to service providers or have visible clinics in the chosen geographical location. However, some GPs, particularly bilingual GPs, can be isolated from other service providers and have low visibility to organisations such as divisions of general practice. To identify these GPs it will be necessary to consult with ethnic health workers and ethnic consumer groups. It is important that these GPs are actively approached to be involved in the shared care program even if they are unknown to service providers. It is likely that these GPs are well known to the ethnic communities they serve. These important GPs may need special

visits to be briefed about the program and the possible benefits to them and their patients. Building personal relationships is an important factor in recruiting bilingual GPs in particular. In the Brisbane inner south project it was found that GPs who had not participated in previous divisional activities carried an enormous load of mental health patients and they formed a valuable component of the shared care program. Furthermore, the shared care program reduced the isolation experienced by these GPs by increasing their referral options and providing valuable clinical consultation opportunities. However, some GPs were reluctant to refer their patients on to other services, believing these to be culturally inappropriate. These GPs needed encouragement to raise these issues in the shared care program and also needed reassurance that they would remain in the role of case coordinator, despite referring patients to other services. GPs require ongoing contact from shared care program staff and may find it difficult to attend set meetings, instead preferring individual meetings with program staff. Negotiations may need to take place about how the program can realistically meet the individual needs of GPs . Skills development Simply having willing participants will not be enough to start setting up shared care arrangements. The participants will need to be trained in

Mental health shared care for ethnic communities – a handbook

Key questions for GP recruitment: • Why do you want to

•

be in the program? (not just to refer mental health patients on) Are you willing to take on mental health patients? (is this a mental health friendly GP?) Are you prepared to be flexible and work differently? Are you willing to offer longer c o n s u l t a t i o n s to mental health patients? Are you prepared to be challenged? (and not feel defensive) Are you willing to collect the data required to be a participant? Are you willing to provide input into the processes and use them?

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Developing relationships, systems & protocols

all aspects of transcultural mental health before the program can be implemented.

The Brisbane inner south project developed the following written communication tools. (They can be perused in the ‘appendices’ section.) • Fax

service

request

form

• GP resource guide • GP resources summary

The GP resource guide included a master copy of an interpreter request form, which is essential to include in ethnic shared care program written materials.

Other program participants may also need skill enhancement on issues such as mental health, general practice and basic things such as using professional interpreters. The following page provides a snap-shot of issues to be covered in training about interpreters, as a guide. One of the major lessons learned from the Brisbane inner south project is that training should not be skimped on. Training is also most useful when it is conducted on an ongoing basis so that trainees can bring their real life practice issues to training. This not only enhances their learning but provides for a much more engaging training experience for all participants.

organised but were poorly attended by GPs. Service providers demonstrated a high level of commitment by consistently attending such meetings but it was not possible in the project, to determine how GPs could be encouraged to participate in such meetings. However, the initial training seminars organised by the ethnic shared care program coordinator were well attended by GPs and service providers alike. Ongoing opportunities for face-to-face meetings are another important component of establishing good communication and goodwill. Program meetings, case discussion as well as training all provide an opportunity for this to take place. Protocols

Communication Mental health services and GPs participating in the shared care program should establish communication as early as possible. According to Keks et al (1998), the best kind of collaboration occurs when GPs and community mental health staff get to know about each other’s role and stay in personal contact. However, this may need to be a facilitated process. Educational meetings organised by the service and/or the local Division of General Practice are a useful opportunity for such networking.

It is likely that the shared care program will develop its own written materials to facilitate the shared care procedures and protocols. These could include referral protocols, information sheets and referral feedback forms. It is essential that a representative from all participant services have input into the development of these communication tools so that they are shared, owned and relevant to all concerned. In ethnic shared care, the translation of some materials into community languages may have significant cost implications.

In the Brisbane inner south project, case discussion meetings were Mental health shared care for ethnic communities – a handbook

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Developing relationships, systems & protocols

GPs can access interpreters from TIS free of charge

Translating and interpreter service The Translating and Interpreter Service (TIS) provides both over-the-phone interpreters at short notice and onsite interpreters that are booked a couple of days in advance. It is important to establish language, ethnic and gender preferences for interpreters and to request these from TIS. The TIS telephone number is 131 450. Telephone interpreters can be accessed 24 hours per day. Accessing telephone interpreters: 1. Call TIS on 131 450. 2. Explain the purpose of your call and nominate the language (and gender/ethnic preference) required. 3. State that the interpreter is required for a doctor’s consultation. 4. You will then be connected to an interpreter in the language you require. 5. The telephone interpreter service can also be prebooked for an extra fee. If the call is booked in advance this will ensure that any special requirements can be catered for. Accessing on-site interpreters: 1. Determine the language, ethnicity and gender required. 2. Complete an Interpreter Request Form (available from TIS). 3. Fax the completed Interpreter Request Form to TIS on 1300 654 151 with reasonable notice – at least a couple of days in advance. 4. TIS will confirm the booking by sending a return fax. Using phone interpreters These can be used if you are with the patient or if the patient is at another location: Same location: 1. Sit with the patient next to a telephone. Put the telephone on the ‘speaker’ function. 2. Call TIS on 131 450 and the operator will connect you to an interpreter in the language you require. 3. Sit facing the patient. Be aware of facial expressions and body language. 4. Speak in the first person at all times. 5. Be sure that the interpreter can hear clearly.

6. Keep the amount of information to be interpreted at any one time short, with one idea per sentence. 7. So that the participants do not talk over each other, include a pause after each sentence. Different locations: 1. Call TIS on 131 450 and ask the officer to contact the required interpreter, who will then call the patient. 2. A three-way conversation can then take place. 3. In the same way, patients can use this service to contact the GP. Using on-site interpreters 1. Introduce everyone and establish roles. 2. Arrange seating to facilitate communication between yourself and the patient. The ideal seating arrangement is a triangle, with participants at equal distances from each other, so that eye contact can be maintained at all times. 3. Maintain eye contact with the patient if culturally appropriate (rather than engaging with the interpreter). Avoid private discussions with the interpreter. 4. Speak directly to the patient, on first person terms. 5. Speak slowly and clearly but naturally. Avoid jargon. If jargon is unavoidable e.g. medical terminology, ensure that the interpreter understands the concept. 6. If you feel that the patient and interpreter are speaking together and excluding you to the extent that you are not establishing communication with the patient, you should stop the interview. Restate the ground rules and start again. 7. Summarise your discussion periodically throughout the interview to ensure shared understanding of what is being said. 8. With consecutive interpreting, use short sentences.

Box 2: Accessing and using the Translating and Interpreting Service Mental health shared care for ethnic communities – a handbook

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CARE PLANNING PROCESSES Care planning is a critical component of shared or integrated care. The contents of a care plan are partly influenced by the program and its aims, but there are generally three models of care: acute, intermediate and long-term. The Brisbane inner south project found that key elements of a care plan included: ·

“We really want the GP to be part of the treatment team, we will set up case conference times to suit the GP, we just need more GPs to work with!” - service provider in the Brisbane inner south project

A list of who was involved in the care and treatment of the person and how to contact them. A person’s met and unmet needs and goals for activity, to be addressed by any clinician or the consumer. A person’s early warning signs of acute and/or worsening illness A brief summary of a person’s mental health history, including d i a g n os i s , d ate of last admission and reasons for admission. A person’s medication history and a clear outline of who is responsible for managing repeat prescriptions, changes in medication and the monitoring of side effects. Date of plan and review date.

However, it was a challenge to get GPs to bring cases along to these meetings. MBS and case management The MBS items for care planning and case conferencing can be used advantageously for shared care. It allows for GP involvement in the development of patient care plans and case conferences, and the opportunity to clearly outline individual roles and responsibilities in patient care. These are all essential components of a shared care program. These MBS items mean that GP involvement is feasible and GPs can be remunerated for their involvement. It is important that the availability of the MBS items be communicated to GPs as early as the recruitment stage, as some GPs may not be aware about the use of these items. Furthermore, MBS utilisation should be addressed in preliminary training. Such training should be attended not only by GPs but all other service providers so that an accurate and sound knowledge is developed by all program participants. This is particularly important as GP involvement in case conferences and care planning can be initiated and requested by service providers.

It can be a challenge to set up a system or process that facilitates the creation of care plans. In the Brisbane inner south project, attempts were made by the project to organise case conferences through the provision of opportunities for GPs and service providers to meet for case discussion. Mental health shared care for ethnic communities – a handbook

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MAINTAINING SHARED CARE Shar ed care projects are an opportunity to establish relationships and develop systems to facilitate ongoing collaboration. However, as most shared care programs operate on time-limited funding, one of the challenges is to sustain the impact and benefit of the program for as long as is feasible. However, it may not be possible to maintain all aspects of the shared care program, particularly if certain functions were carried out by program staff, rather than program participants themselves. These tasks could include: Facilitation of case discussions • Ongoing training • Administrative support •

• • • •

Coordination of meetings Li ai s on be tw ee n program participants Trouble shooting Ongoing recruitment of GPs

Such tasks should be considered from the outset to determine if they are time-limited by the establishment phase, or ongoing and essential to program operation. There were a number of issues that the B r i s b a n e in n er sou th pr oj e c t considered from the outset to maximise the project’s sustainability and maintenance beyond the funded life of the project. These appear in Table 4 below.

Strategy to sustain the program

Specific issues to consider

Ongoing meetings between program participants to monitor and review shared care processes.

•

Ongoing training and professional development to maintain interest and relevance.

•

Integration of ethnic shared care into a mainstream program.

•

• •

Commitment of all parties to the program Time commitments necessary to participate and attend meetings

Training program to be drawn up from the outset Some training at commencement but ongoing training thereafter

Partnership with a relevant mainstream program from the outset Establishment of parallel processes Clear integration plan from the outset

Table 4: Strategies and considerations for program sustainability

Mental health shared care for ethnic communities – a handbook

“We vaguely know what is around but don’t have the opportunity to really find out, unless you get involved in a project like this. It is great to build the relationship and we must continue to build the relationship.” - GP in the Brisbane inner south project

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EVALUATING THE PROGRAM The evaluation framework ideally should be developed at the planning stage of the program. An evaluation framework usually involves the collection of data to answer questions about program process, impact and sometimes, outcome. Thus the first step in developing an evaluation framework is to set the evaluation questions. These may include questions about the effectiveness of program processes, the impact of training or the program

Patients

itself on participants, or any intended or unintended outcomes. The next step is to develop data collection tools that will answer the evaluation questions. It may also be possible to use existing data collection p r oc e ss e s such a s statistical i n f ormation that organisations routinely collect, for the evaluation. The perspective of the three main participant groups (consumers, GPs and services) should guide the development of data collection tools to ensure that the tools will be accessible

Measures

Accessibility & feasibility

Levels of satisfaction Levels of access

GPs required for access to patients and to obtain consent. Interviews were accessible and feasible once ground-work was achieved.

Tool: personal in-depth interviews Service providers

Referral numbers Program processes – satisfaction and efficiency

Service data could not be relied on because inadequate records were kept by services. Focus group was used for feedback.

Tool: focus group GPs

Program processes – satisfaction and efficiency Use of referral options Use of program resources Tool: pre and post-training questionnaires, focus group, telephone interviews, GP check list, GP case studies

Focus group was used for feedback but was poorly attended. Individual telephone interviews were used to augment information from focus group. GP check list relied on intervention & control groups to compare impact of intervention. This was difficult to facilitate and only small numbers of GPs participated. Case study data provided rich information.

Table 5: Evaluation strategies in the Brisbane inner south project from the perspective of three participant groups

Mental health shared care for ethnic communities – a handbook

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Evaluation

and realistic. Considerable negotiations with the participant groups will need to take place from the outset of the program to discuss the type of data that is required from them. Groups should also be given input into the development of tools to ensure that they will be used. Step three involves the development of indicators that will answer the evaluation questions. Some examples of indicators are: A 25 per cent increase in referral â&#x20AC;˘ to mental health services by GPs Demonstrated improvement in â&#x20AC;˘ knowledge by mental health workers in transcultural mental health practices.

perspectives about the program, or, the perspectives of the three groups may be triangulated and considered equally. The analysis framework may also provide a guide on the methodology for data analysis. Group processes such as evaluation workshops involving program participants could be used, or program staff could themselves analyse the data or perhaps an external consultant could be used. The table on the next page provides an example of the evaluation strategies used in the Brisbane inner south p r o j e c t , t o m e asu re p r og r am effectiveness (excluding the cost analysis).

Fourthly, all the participants who are required to collect data must be trained and briefed about the evaluation and what is required of them. Time-frames should be set and regular contact should be made with participants to ensure that the data collection tools are being used correctly. Finally, an analysis framework should be developed. An analysis framework guides the analysis of the evaluation data. The framework may contain information about the weighting of different perspectives. For example, the perspective of consumers may take precedence over other

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Evaluation

Training course Evaluation question

Data collection tool

Indicator

Who to collect

Has the training increased GP knowledge and understanding of transcultural mental health issues?

Pre and post questionnaire

Improvements in knowledge Project coordiand understanding demon- nator strated by GPs

Has the training course inPre and post questioncreased GP skills in identify- naire ing mental illness in patients of NESB? GP checklist

Identification rates by GPs who undertook training and GPs in the control group (non-trained)

Project coordinator

Has the training course increased GP awareness of available mental health services?

Improvements in GP awareness of services

Project coordinator

GP stated intention to participate in shared care

Project coordinator

Pre and post questionnaire GP checklist

Has the training enabled Content evaluation GPs to be active participants questionnaire in shared care? GP check list

GP actual participation in shared care

Number of communications/referrals to mental health services Has the training increased GP confidence in identifying mental illness in patients of NESB?

Self reporting by GPs in Increased level of confiProject coordiquestionnaire/ interdence nator view Increased number of menGP check list tal illnesses identified by active GPs

Shared care What are the systems developed and implemented by the project of facilitate shared care?

Project data Utilisation rates by service providers - GP check list - Service data

Number of systems impleAll service promented viders Systems are utilised by relevant service providers as agreed within the program Quality and frequency of communication between services

Are GPs able to make appro- Service data priate referrals to mental health services?

Number of referrals

Service providers

Are GPs using the new MBS items to participate in shared care?

GP check list

Number of items claimed per GP

Project coordinator

What is the impact of the shared care program on the level of satisfaction of key stakeholders?

Service provider and GP focus group

Stakeholder satisfaction

Project coordinator

Appropriateness of referrals

Patient interviews

Table 6 â&#x20AC;&#x201C; Evaluation framework for program effectiveness in the Brisbane inner south project Mental health shared care for ethnic communities â&#x20AC;&#x201C; a handbook

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CONCLUSION It is hoped that the issues and practical strategies outlined in this handbook will assist others to plan, implement and evaluate their own ethnic mental health shared care programs. Ethnic mental health shared care can improve the quality of services received by people of NESB with mental health problems and should therefore be considered to be an important component of all mainstream mental health shared care programs. The Brisbane inner south ethnic mental health shared care project, although a

small demonstration project, did contribute valuable information and insights into ethnic mental health shared care. In particular, the project demonstrated the positive impact of GP training, with significant differences recorded in GP responses to patients of NESB with mental health problems. The primary pathway to mental health care for people of NESB often starts with the GP and therefore, despite the challenges of setting up shared care, it is well worth persevering, to achieve more equitable outcomes for people of NESB with mental health problems.

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REFERENCES ACCESS SERU, Sharing Mental Health Care A Guide for Divisions of General Practice, SERU, 1997 Andrews, G Hall W, Teesson M & Henderson, S, The Mental Health of Australians, Commonwealth Department of Health and Aged Care, Mental Health Branch, Canberra, 1999 De Bruyn, Evaluation of programs for the treatment of schizophrenia: a health economic perspective, Health Canada, 1994, www.hc-sc.gc.ca/hppb/mentalhealth/pubs/evaluation Fitzgerald, M (1992) ‘Multicultural Clinical Interactions’, Journal of Rehabilitation, April-June, 3842. Hickie, I B, ‘Primary care psychiatry is not specialist psychiatry in general practice’ in Medical Journal of Australia, 1999; 170: 171-173 (http://www.mja.com.au/public/issues/feb15/ hickie/hickie.html) Keks N, Altson B, Sacks T, Hustig H and Tanaghow A, ‘Collaboration between general practice and community psychiatric services for people with chronic mental illness’, Medical Journal of Australia, 1998, www.mja.com.au/public/mental_health/articles/keks2/keks2.htm/, pp1-2 Kleinman, A Esenberg, I and Good, B, ‘Culture, illness and care: clinical lessons from anthropological and cross-cultural research‘, Annals of Internal Medicine, 1978:88 Lehn A, ‘Recent Immigrant’s Health and their Utilisation of Medical Services. Results from a longitudinal Survey of Immigrants to Australia‘, Department of Immigration and Multicultural Affairs Immigration update, March Quarter, 1997 Mazza, D ‘A coordinated national approach to clinical practice guideline implementation for GPs’ To Their Full Potential: Evidence based guideline uptake in primary mental health care. Conference Proceedings, Centre for General Practice Integration Studies, UNSW, 2000 McDonald R and Steele Z, Immigrants and mental health: an epidemiological analysis, TMHC NSW 1997 Mihalopolous C, Pirkis C, Naccarella L and Dunt D, The Role of General Practitioners and other Primary Care Agencies in Transcultural Mental Health Care, ATMHN, Vic, 1999 Minas, H, Texbook of Community Psychiatry , Oxford Press, Melbourne, 2000 Nelson K, Cumming J, MacEwan V, ‘Early lessons in shared care: experience from a pilot involving general practitioners in the care and treatment of people with ongoing needs from mental health services’, Geigy Psychiatric Symposium, Dec 1997, pp 71-71. Silove D and Steele Z, The mental health and well-being of on-shore asylum seekers in Australia, Psychiatry Research & Teaching Unit, Liverpool Hospital, NSW 1998

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Appendix 1 – Protocols used in Brisbane inner south project: GP resources summary

appendices

IMPORTANT COMMUNICATION TOOLS:

1. TIS Fax Booking Form Use when an on-site interpreter or pre-booked telephone interpreter is required. At least 48 hrs notice is required. 2. Fax request Form Use when access to staff from the following organisations is required to discuss follow up support for your patient: • • • •

Ethnic Mental Health Program (bilingual support workers) Qld Program of Assistance to Survivors of Torture and Trauma Transcultural Clinical Consultation Service Psychiatry consultation and liaison service (BISDIV)

3. MHS Intake and Referral Form If you have diagnosed your patient, use this form when making a referral to the Adult Mental Health Service. When filled in completely the referral will go straight through to a team review meeting and bypass the assessment process. A photocopy is acceptable so you can keep the form for your records if you wish.

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appendices

Appendix 2 – Protocols used in Brisbane inner south project: fax request form NESB MENTAL HEALTH SHARED CARE PROJECT FAX REQUEST FORM To (tick service Name of service required)

Fax number

Ethnic Mental Health Program

Fax 3891 7922 Ph 3891 7911

Qld Program of Assistance to Survivors of Torture and Trauma

Fax 3391 6388 Ph 3391 6677

Qld Transcultural Mental Health Centre Clinical Consultation Service

Fax 3240 2282 Ph 3240 2833

Brisbane Inner Sth Division of General Practice Psychiatry consultation and liaison

Fax 3392 2920 Ph 3392 2822

From: Dr Phone: Fax: Mobile: Date: Best time to ring me back:

Transcultural Mental Health Centre Clinical Consultation

Support and follow up for patient Support and education for family Case discussion re ongoing management of patient Joint assessment and interview with patient

Information

Regarding culture of patient Regarding other support services within cultural group Regarding mental health services Mental health information

Shared care

Follow up on shared patient Case conference requested Update on care plan

Patient support

Support and follow up for patient Case discussion re ongoing management of patient Specialist counselling for refugee patient Request for joint assessment and interview with patient

Shared care

Follow up information on shared patient Case conference requested Update on care plan

Assessment & diagnosis and short-term intervention

Case discussion re cross cultural and clinical input into assessment Information about available services for patient Request for joint assessment and interview with patient Short term counselling for patient Psycho-education for patient/family

Case discussion with a psychiatrist Request for joint assessment and interview with patient

BISDIV Psychiatry Assessment & diagnosis Consultation and Liaison

Mental health shared care for ethnic communities – a handbook

Preferred language: Duration in Aust:

QPASTT

Patient support

Patient details: Ethnicity: Age:

Ethnic Mental Health Program

Gender: M F Duration of illness:

I request the following service(s) for my patient:

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appendices

Appendix 3 – Protocols used in Brisbane inner south project: GP quick reference guide

NESB Mental Health Shared Care Project When to use fax request form Resources available to project GPs 1. Clinical Consultation and liaison Dr Frances Dark will visit your surgery at a time convenient to you for case discussion or joint consultation with patient for assessment and diagnosis. Use fax request form to request a visit from Dr Dark 2. Clinical Consultation and liaison (Transcultural) Contact Polly Nip at Transcultural Mental Health Centre for access to a bilingual/bicultural mental health professional to provide input into assessment, diagnosis or other care management issues. Can also provide short term interventions such as counselling. Use fax request form to request a service from Polly. 3. Bilingual mental health support worker The Ethnic Mental Health Program has mental health support workers who are Vietnamese, Chinese, Spanish speaking, Croatian, Greek and Italian who can provide one on one support to your patient and their family. The program also has a range of support groups. Use fax request from to request a service from Valentina, coordinator Ethnic Mental Health Program 4. QPASTT Specialist services available through QPASTT for refugees who are survivors of torture and trauma. These services include counselling, case work support, youth program, children’s program and natural therapies program Use fax request form to request a service from QPASTT

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appendices

Appendix 4 â&#x20AC;&#x201C; Protocols used in Brisbane inner south project: GP resource guide

Shared Mental Health Care for people from non English speaking backgrounds Brisbane Inner South Division of General Practice Brisbane Southside Central Division of General Practice Queensland Transcultural Mental Health Centre Ethnic Mental Health Program Queensland Program of Assistance to Survivors of Torture and Trauma Adult Mental Health Services (Coorparoo, West End, Inala)

The following information is for General Practitioners, Mental Health Professionals and non-government agencies supporting NESB people with mental health problems with the objective of promoting better communication and systems between health professionals to facilitate shared care. The aim of this document is to provide you with an easy to follow reference guide and checklist on who you can contact and liaise with to support you in providing optimum care to your patient. We hope you find this information useful and easy to use and invite you to make use of the support and resources that are available to you and your patients and that the enclosed referral forms will facilitate easy access to services. You may also find that as you are using this information, that you have questions or suggestions to improve this information. Please contact us at: Brisbane Inner South Division of General Practice PO Box 8004 Woolloongabba Q 4102 Ph 3392 2822 Fax 33922920

Mental health shared care for ethnic communities â&#x20AC;&#x201C; a handbook

Less severe mental disorder and lack of clarity about presenting condition

Severe mental disorder

Greek Italian Chinese Vietnamese Spanish speaking Former Yugoslav

Patient is from one of the following ethnic backgrounds:

Torture and Trauma

Transcultural issues

English language difficulty

Patient Characteristic

Interpreter Service Clinical Consultation Service

Support Service Adult Mental Health Service

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appendices Appendix 4 â&#x20AC;&#x201C; Protocols used in Brisbane inner south project: GP resource guide

QUICK CHECK TO DETERMINE SERVICE AVAILABLE CHECKLIST AND CONTACTS

Mental health shared care for ethnic communities â&#x20AC;&#x201C; a handbook

Patient is from the follow- All phases of care, es- Bilingual support worker to ing ethnic background pecially ongoing care support patient with treatment and follow up Chinese Vietnamese Education for carer/family Greek Italian Former Yugoslav (Croatian, Serbian, Bosnian) Spanish speaking

Specialist counselling

Refugee Background

Survivor of Torture and Trauma

Development of treatment plan Short term counselling All phases of care Health support

131450

Ph 3891 7911 Fax 3891 7922

Ethnic Mental Health Program

Ph 3391 6677

Qld Program of Assistance to Survivors of Torture and Trauma

Specialist consultation by ses- Transcultural Clinical sional bilingual worker for as- consultation Service Consultation to estab- sessment and diagnosis lish history Ph 3240 2833 Case discussion for ongoing Fax 3240 2282 Assessment, diagnosis management of patient

Admission/intake

Transcultural issues

Translating and Interpreting Service

Key phase of care Service/Resource avail- Contact able

Unable to communicate in All phases of care English

Patient Characteristics

Fax request form

Fax booking form for onsite interpreting and pre booked telephone interpreter.

Access/ Referral Protocol

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Appendix 4 â&#x20AC;&#x201C; Protocols used in Brisbane inner south project: GP resource guide

appendices

Mental health shared care for ethnic communities â&#x20AC;&#x201C; a handbook

Assessment

PAH Mental Health Assessment Team Weekends and Public Holidays 10.00 am – 6.00 pm

PAH Mental Health Assessment Team Mon-Fri 3.00 am – 11.00 pm

Coorparoo Mon – Fri 8.30 am – 5.00 pm (by phone)

Intake, assessment and Coorparoo Mon-Fri 8.30 am- 3.00 pm referral (in person)

If patient is diagnosed by GP the Intake Referral Form can be completed by GP and forwarded to local mental health service, which will go to a team review meeting. This is preferable for patients who have a language barrier as an interpreter can be booked by the servLess severe mental illness Assessment, diagno- Clinical consultation from Brisbane Inner Sth Division of General Fax request form sis, and developa psychiatrist Practice Lack of clarity about pre- ment of treatment senting condition plan Ph 3392 2822 Fax 3392 2920

Non acute

Severe mental illness (acute)

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appendices Appendix 4– Protocols used in Brisbane inner south project: GP resource guide

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acknowledgments This handbook was developed by Marina Chand on behalf of the Brisbane Inner South Division of General Practice. It was developed with the assistance and input from Marco Ramirez, Brisbane Inner South Division of General Practice and Rita Prasad-Ildes from the Queensland Transcultural Mental Health Centre. Special thanks and appreciation to the following members of the project reference group who found time in their busy schedules to provide valuable comments and feedback: Sue Gargett Amanda Kivic Alison Smith Dr Robert Zubeshaw

School of Public Health, Queensland University of Technology Team Leader, Coorparoo Adult Mental Health Service Brisbane Southside Central Division of General Practice General Practitioner

Thank you also to other members of the reference group: Dr Frances Dark, Robyn Prince, Glenys Powell, Donata Rossi, Valentina Dimoska and Damian Stanley-Jones and all the consumers and service providers who agreed to be interviewed and/or attend feedback meetings.

Mental health shared care for ethnic communities â&#x20AC;&#x201C; a handbook