Priority 4 - A Spectrum of Acute and Community Care

There’s a real revolving door syndrome – people get admitted, they get treatment and then they get discharged but because there’s no supported accommodation for them they keep coming back into the hospital.

Clinician, South Australia, Murray Bridge Forum #5, Not For Service,

Time for Service is primarily concerned to move to a more community-based system of mental health because, with appropriate support, the best place for people to receive care is at home.

Initiatives which focus solely on expanding beds, especially acute care beds, will fail to deliver fundamental reform and good outcomes for the community.

Time for Service calls for 40% of spending on the acute care sector to be devoted to acute mental health services provided in the home, not hospitals. New and innovative pathways are needed to provide a choice of effective services to consumers.

If somebody is becoming acutely unwell, the system should deliver acute care first at home. If a person attends the emergency department of a hospital, it should be possible with appropriate support, for the person to return home, avoiding a hospital admission. If admission to an acute ward is unavoidable, again it should be possible to be discharged directly to home to receive ongoing community supported recovery services.

If going home isn’t possible straight away, the system should offer this same suite of clinical and non-clinical services plus access to short to medium term accommodation options (step-down care). These same options should be available for people if they become unwell at home but before they become acutely unwell and require hospitalisation (step up care).These community-based clinical and non-clinical services and these pathways do not exist now or are seriously underfunded.

Most acute care services are currently in crisis and often fail to provide good quality care. Most state and territory governments have already committed to further investment in acute hospital beds — Time for Service does not call for additional funds specifically for acute beds located in hospitals.

It is Time for Service designed to enable a successful return to home, study and work following an acute episode of mental illness.

This means funding a new spectrum of acute care with the best balance of services, from home-based acute care, through to hospital care, step-up/step down care in the community and longer term care options.

Initiatives which focus solely on expanding beds, especially acute care beds, will fail to deliver fundamental reform and good outcomes for the community.

The cornerstone of Time for Service is a call for concerted investment in clinical and non-clinical community-based services, particularly services accessible from home. This type of investment is designed to avoid a bed-based mental health system. However, in any mental health system, one part of the spectrum of care required will be mental health beds in health services. As a guide to planning, these beds should be allocated in the following proportions:

Emergency Department Beds	5% of all beds
Intensive Care Hospital Beds	10% of all beds
Acute Care Beds in Hospital (<28 day stay)	30% of all beds
Community Supported Recovery Service Places (up to six months stay, provided as step up/step down care)	30% of all beds
Extended Care Beds (1-2 year stay)	10% of all beds
Indefinite Care Beds	15% of all beds

 

The CSRS places, as explained later, will only be required where it is not possible to provide the suite of clinical and non-clinical support services at home.

Extended and Indefinite Care

It must be acknowledged that for a group of people with mental illness, the goal of return to home is unlikely to ever be achieved. For a range of reasons and particularly because they have not had access to the type of services called for in Time for Service , these people have lost connection with their families, are homeless or are unlikely to ever be able to live successfully in the community. These people are a critical but small group, often with very high support needs, who must be provided with appropriate services and accommodation.

The mental health system described in Figure 2 indicates the importance of catering for this group. In such cases, extended care and indefinite care options must be available (about 25% of total system beds). There are already successful models and investment in Australia where stable public housing is mixed with clinical and non-clinical support services to substantially improve the quality of life for people with a mental illness.¹⁰

But the focus of Time For Service is different and quite clear – it is to put in place services specifically designed so that people stay connected to their home, their job and the people who love and support them. Maintaining and strengthening these crucial social connections should underpin the objectives of all mental health services.

Across the spectrum of acute and community care services, consideration needs to be given to engagement of the private sector in building and servicing appropriate facilities, particularly for certain groups such as mood disorders, eating disorders, post natal depression and psycho-geriatric services. The nature of these disorders increases their suitability for management within voluntary care settings.

4.1 Acute Care Outside Hospital

Clinical services leave clients till they are so unwell that they have to be hospitalised.

Anonymous, Northern Territory, Submission #188, Not For Service, p. 748

It is Time for Service for people so they can receive acute mental health care without needing to be admitted to hospital.

Preventing admission to acute hospital care relieves pressure on the emergency care system which is choking. It is also associated with better social and vocational outcomes and removes the concern about secondary morbidities and additional trauma that are often a consequence of acute hospitalisation.

Each area health service would need to develop a designated team to provide in-home acute care. Each team would not only provide intensive and multi-disciplinary clinical services such as nurses, doctors, psychology services but also strongly emphasise practical family support services, counselling, interventions and employment support services to enable successful return to work or study. Note that this is not an acute care service for those who are homeless or in poorly supported accommodation, such as hostels.

This style of service has never been routinely provided in Australia despite two decades of evidence of its efficacy¹¹. When provided appropriately and properly integrated with other services, this service would not be cheaper than the current cost of hospitalisation but would serve to prevent hospitalisation.

This service will fail unless there is a network of community supported recovery services available to assist both the consumer and their family during and following the acute illness.

Expenditure Required: $200m per annum.

4.2 Community Supported Recovery Services (CSRS)

After exhibiting psychotic behaviour my son spent 21 days (detained) in Glenside Hospital in March 2002. He was counseled and medicated then turned out into the community with some medication but no follow up care. Shortly afterwards he stopped his medication, reverted to his anti-social, aggressive and irrational behaviour, a state he has been in unchecked for two years.

Carer, Mother, South Australia, Submission #11, Not For Service, p. 21

There is a need for appropriate transitional models of care between hospital and community.

Anonymous, Tasmania, Submission #254, Not For Service, p. 800

It is Time for Service to give people the care they need to continue their recovery following discharge from an acute hospital. We need a new model of care - the Community Supported Recovery Services (CSRS).

The CSRS model is designed to realise the goal of enabling independent living at home. This goal will fail unless a full range of community services is developed, including primary care, vocational rehabilitation and a range of psycho-social support services designed to help people recover and stay well.

As many as 40% of people currently occupying acute mental health inpatient facilities could be discharged from these facilities if suitable services and supports were available.

The CSRS model of care is about getting the mix right between clinical and non-clinical care. It is sometimes called ‘stepped care’, ‘step-up/step down care’ or ‘transitional care’ – this is a model of care designed to provide additional support following discharge from an acute hospital. All care should be provided at home wherever possible. Where this isn’t possible, accommodation options must be part of the CSRS model of care. The CSRS model should work to prevent hospital admissions

Community Supported Recovery Services work alongside people with a mental illness. These programs are predominantly delivered by the NGO sector to provide essential support to assist people with housing, activities of daily living, social skills, community access, social and recreational activities, counselling and advocacy, financial skills and management, vocational and employment support as well as general and specialist information sharing.

Services can be delivered through individually tailored programs or group activities that assist people gain or develop new skills to manage and maintain their mental health and deal with the impact their mental illness has had on their lives. These non-clinical services must work alongside clinical treatment services with the goal of assisting people to live successfully in the community. Some bed based rehabilitation services are essential and useful as part of a rehabilitation continuum, but the prime focus must be on assisting people to develop/redevelop their skills in as normalised an environment as possible and in a way that assists people to integrate with and reconnect with their community.

Australia’s mental health system is not designed to keep people well now. The average length of hospital stay for acute mental illnesses such as schizophrenia is far too brief to initiate real recovery in the course of an acute hospital stay.

At the same time it is estimated that 30% of patients currently on acute care wards in public hospitals are no longer acute and could be cared for at home or elsewhere with appropriate support. Readmission rates to acute hospital care are unacceptably high.

Because the necessary support is not available in the community, acute care beds are blocked and people are commonly discharged from hospital having received insufficient clinical or non-clinical mental health service. Without the necessary follow-up care or support, people can become quickly unwell enough to require further admission to hospital. This is both unacceptable and inefficient - the so-called ‘revolving door’ in our acute care system.

The CSRS are a critical piece of service infrastructure never systematically funded following deinstitutionalisation. With proper investment in CSRS, it should be possible to receive ongoing step-down clinical and non-clinical services at home following discharge.

Similarly, if an episode of mental illness is commencing, it should be possible to ‘step-up’ the level of clinical and non-clinical care available minimising the escalation of problems and avoiding hospital admissions.

CSRS are not holding bays or merely supported housing but have a clear focus on recovery, delivering a mix of clinical and non-clinical services to achieve this, including accommodation if necessary.

If care at home isn’t possible, the CSRS model of care should also offer stable, short to medium term accommodation options (<6 months) in which this same suite of transitional care, clinical and non-clinical services can be provided. Accommodation options as part of CSRS should also act to increase the availability of acute care beds and thus reduce time spent in emergency departments by patients requiring acute admission.

This type of transitional accommodation option is not a significant feature of Australia’s mental health system currently but must become a real option for those still requiring clinical and non-clinical services on discharge from an acute hospital, and where these services cannot be provided at home.

While the CSRS are focused on home-based support, step-up/step-down accommodation options should constitution about 30% of all mental health system beds .

Vocational rehabilitation needs to feature as early as possible in the course of a person’s recovery from mental illness. As a person recovers from an acute illness, their requirement for clinical and community mental health services declines while the importance of vocational rehabilitation and community support increases (see Figure 3). The CSRS are designed so that 50% of the budget for each CSRS will be spent on vocational services. CSRS will provide a stable clinical environment in which detailed vocational assessment and relevant education and training can be provided for a period of around six months. CSRS are not designed to provide extended or indefinite care.

CSRS are the crutches you need until the plaster comes off and you can stand on your own two feet.

CSRS can usefully be differentiated to meet the needs of specific groups: those still at school; those with comorbidities; those with children; the elderly etc. This targeting will not only benefit those groups who currently find it difficult to access the services they need, it will also encourage the maximum number of private and NGO providers to be involved in running and managing the CSRS.

A small number of step-up/step-down services already exist in Australia but these have most often become mere extensions of acute care wards providing cheaper care to people with established illnesses.

By contrast, CSRS must have a true recovery focus based on close interaction between clinical and non-clinical services and a range of psycho-social support services. Community services and consumer-operated services can often provide effective peer support and assistance.

Investment in CSRS needs to occur in each state and territory. WA and Victoria have already commenced.

While the bulk of community supported recovery services should be available in the home, in order to facilitate accommodation options, there is a requirement across Australia to commission 1000 step-up/step down CSRS-type places over the next four years with further investment required from 2010.

To develop these CSRS places, it will be necessary to build new stock or re-commission existing community hospital stock. There will be movement of patients from more expensive acute care beds in general hospitals which are estimated to cost as much as $800 per day. By contrast, it is estimated that properly configured CSRS accommodation services would cost in the order of $200 per day. The balance of the CSRS funding is for the community supported recovery services necessary to make this model work. These services would be spread between those provided at, or from home, and those provided as part of short-medium term accommodation solutions.

It is envisaged that CSRS could be run and managed by public, private or non-government organisations.

Estimated cost
Community supported recovery services per annum	$330m
step up/step-down accommodation options	$70m
Total cost	$400m