Activity Work Plan 2019-2022: Primary Mental Health Care Funding Perth North PHN - WAPHA
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Activity Work Plan 2019-2022:
Primary Mental Health Care Funding
Perth North PHN
Approved by the Australian Government Department of Health, September 2019 (Version 1)(a) Planned activities for 2019-20 to 2021-22
– Primary Mental Health and Suicide Prevention
Funding
– Indigenous Mental Health Funding
– Response to PFAS Funding
Proposed Activities
Mental Health Priority area 7: Stepped care approach
Priority Area
MH1.01a: Development of a Standardised Comprehensive Initial Clinical
ACTIVITY TITLE
Assessment and Referral Pathway to a Virtual Assessment Clinic
Existing, Modified, New Activity
or New Activity
PHN Program Key Mental Health
Priority Area
Priority:
• PNMH 2.4 Increase access to low cost- local mental health services in outer-
suburbs and areas with limited service availability but high demand. (p.88)
Possible Option:
Needs Assessment • Support integrated online, telehealth and face to face services i.e. online and
Priority telehealth services. (p.88)
Priority:
• PNMH 2.8. Build capacity with General Practice to recognise and support
patients with mental health conditions and ensure General Practitioners are
aware of appropriate clinical pathways and referral processes. (page 91)
The aim of this activity is to develop a standardised comprehensive intake
assessment process (based on the PHN Initial Assessment and Referral in Mental
Healthcare guidance) to enable general practitioners (GPs), other primary care
clinicians and their patients to make informed treatment choices to improve the
targeting of psychological interventions within an explicit shared decision-making
framework.
The draft initial assessment and referral guidance makes specific
recommendations concerning the form, scope and required skills necessary to
Aim of Activity ensure all patients can receive a standardised comprehensive initial assessment
by a suitably qualified and experienced clinician at the point of entry into
stepped-care. The development of the standardised process to a virtual initial
assessment clinic will be aimed at supporting GP decision-making and referrals to
psychological treatment services, including Better Access and WA Primary Health
Alliance commissioned services. The establishment of such a process will also
provide recommendations concerning possible treatment supports necessary to
promote equitable access to psychological treatment services for the target
group.
2Moreover, this activity will be aimed at providing a consistent, standardised
initial assessment by suitably skilled clinicians, no matter the location of the
individual across the Perth North PHN region. The standardised initial assessment
process for the virtual clinic will also provide GPs with a central point of access
and provide a clinical formulation and specific recommendations for an individual
within the stepped care strata. Thereby, promoting equitable access for all
individuals, particularly in areas of low service availability and high demand, as
well as coordinated care for people with multiple morbidities and treatment
support needs.
A priority of the standardised intake process is to enable patients to receive a
comprehensive initial assessment that will ensure identified treatment options
are proportionate to need and can be aligned, discussed and decided upon
within a shared decision-making approach. This will minimise treatment burden
and maximise therapeutic and other benefits.
This activity recognises the central role that GPs have in both guiding and
supporting treatment decisions that not only consider potential benefits and
risks, but also the values, circumstances and preferences of patients. This activity
is linked to MH1.02 – the development of regional service maps that specify
available treatment and care options within the stepped-care strata (low,
moderate, high intensity), as well as other relevant groupings (age, gender, etc.),
and to a virtual assessment clinic - that can provide GPs with a standardised core
assessment with identified treatment options and recommendations.
This development of a standardised intake process will provide referring GPs with
a standardised comprehensive assessment report including formulation and
specific recommendations, and local service options. The comprehensive initial
Description of assessment will be undertaken by an appropriately qualified health professional
Activity (clinical psychologist, social worker/occupational therapist/registered
psychologist with specific experience in mental health, mental health nurse, or
equivalent). This will also meet the requirement for a GP Mental Health Care plan
or equivalent for referral into PHN commissioned psychological therapy services.
The initial assessment report will be stored in a secure form that can be accessed
remotely by authorised individuals (GPs and clinicians involved directly in the
provision of treatments), incorporated into GP practice software, and My Health
Record, as appropriate.
Work will be undertaken to develop and implement the standardised intake
process through a staged project management approach, including
comprehensive organisational change management. The latter will be required to
modify current processes within the Perth North PHN to align with the Initial
Assessment and Referral in Mental Healthcare Guidance and this activity, so that
commissioned treatment and support services maintain the capability to meet
demand and accommodate the workflow changes required to meet the new
design.
This activity will be targeted at those who are:
• at risk of, or with mild to moderate mental illness, and, in some
Target population circumstances, severe mental illness who can be most appropriately
cohort managed in primary care
• from an underserviced population
• unable to equitably access MBS treatments due to factors indicating
disadvantage, including:
3o low income or inability to access services during business hours
o job insecurity
o material disadvantage
o limited personal resources
o social isolation
o poor health literacy
o other social, economic, cultural and personal reasons
• experiencing locational disadvantage.
Indigenous specific No
Coverage Perth North PHN
The Perth North PHN will continue to engage and consult with a range of key
stakeholders to continue to build trusting relationships, shared ownership and a
common understanding of this activity.
Stakeholder consultation and engagement will occur with:
• GPs
• nurse practitioners
• Australian Government Department of Health
• WA Department of Health
• WA Mental Health Commission
Consultation • North Metropolitan Health Service
• East Metropolitan Health Service
• Royal Australian College of General Practice
• Consumer and Carer Peak Bodies and Consumer Associations
• PHN commissioned mental health service providers
• Primary mental health professionals
• Australian Digital Health Agency
• Metropolitan Clinical Councils
• Metropolitan Community Advisory Councils.
The consultation and engagement activities will be conducted through a range of
methods including face-to-face and group sessions, and online platforms.
The Perth North PHN will continue to collaborate with a range of key
stakeholders to formulate solutions, define role, responsibilities and likely
outcomes, and incorporate their advice and recommendations into the final
model.
The role of key stakeholder will be:
• GPs and clinical editors who will assist in the scoping of the design and
implementation of the initial standardised assessment process.
• North Metropolitan Health Service, East Metropolitan Health Service, Child
Collaboration and Adolescent Health Service/Women and Newborn Health Service, and the
WA Mental Health Commission will support to strengthen regional strategic
partnerships and provide information and clarity regarding transition points
into state based mental health services.
• community and consumer groups who will enhance the PHNs understanding
of consumer needs and desired consumer experience.
• PHN commissioned service providers who will assist in determining the
impact of the new standardised assessment on current practices and seek
input in its design and implementation.
4• relevant peak bodies representing local community organisations and
associations who will assist to inform decisions and formulate solutions
where required.
Activity start date: 1/07/2019
Activity end date: 30/06/2022
Service delivery start date: July 2021
Service delivery end date: June 2022
It is envisaged that the key milestones for this activity will be:
• recruitment of an external project consultant to scope and plan the initial
Activity milestone project specification, and
details/ Duration • completion of the project plan outlining workstreams with detailed timelines.
This will include:
o completion of consultation and engagement activities
o formulation of process to develop a virtual assessment clinic
o development of change management plan
o implementation of change management activities / processes
o development of framework to assess the process’s impacts and efficacy
o implementation of the completed intake and assessment process.
1. Please identify your intended procurement approach for commissioning
services under this activity:
☒ Not yet known
2a. Is this activity being co-designed?
Yes
Commissioning
2b. Is this activity the result of a previous co-design process?
method and
approach to No
market 3a. Do you plan to implement this activity using co-commissioning or joint-
commissioning arrangements?
No
3b. Has this activity previously been co-commissioned or joint-commissioned?
No
No
Decommissioning
This activity does not include any decommissioning of services.
Yes
Data collection Once fully implemented, this activity is in scope for data collection under the
Mental Health National Minimum Dataset.
Following activities will be conducted under operational/administrative activity
costs and have been included as a total (for all activities listed) in the table
below:
MH1.01a
Total Planned MH1.01b
Expenditure MH1.02
MH1.03
MH1.03a
MH1.03b
MH1.04
5MH1.05
MH1.06
MH4.02
MH5.02
MH8
Note: Once the development and implementation stage has been finalised and
activity costs have been determined, funding for commissioned services under
the Activity Work Plan will be reviewed to allow funding of the activities (if
required).
Funding Source 2019-2020 2020-2021 2021-2022 Total
Administration $1,848,434 $1,879,311 $1,246,634 $4,974,379
Total Planned $1,848,434 $1,879,311 $1,246,634 $4,974,379
Commonwealth Expenditure
Proposed Activities
Mental Health Priority area 7: Stepped care approach
Priority Area
MH1.01b: Development of a Standardised Comprehensive Initial Clinical
ACTIVITY TITLE Assessment for People with Mental Illness in Residential Aged Care Facilities
Existing, Modified, New Activity
or New Activity
PHN Program Key Mental Health
Priority Area
Priority:
• PNMH 2.8 Build capacity with General Practice to recognise and support
patients with mental health conditions and ensure General Practitioners
are aware of appropriate clinical pathways and referral processes. (p.91)
Needs Assessment Priority:
Priority
• PNMH 2.10 Support the mental health of older people and assist primary
care providers to identify older people who may need additional support or
referrals to services. (p.92)
No suitable options available.
The draft initial assessment and referral guidance makes specific
recommendations concerning the form, scope and required skills necessary to
ensure all patients can receive a standardised comprehensive initial assessment
by a suitably qualified and experienced clinician at the point of entry into
stepped-care. This aligns with the guidance for Psychological Treatment
Aim of Activity Services for People with Mental Illness in Residential Aged Care Facilities
(RACF), which also identifies the requirement to consider the specific needs
and circumstances of older adults who reside in aged-care facilities.
The aim of this activity is to develop a standardised initial comprehensive
assessment and treatment pathway, that considers the complexities of ageing
and multi-morbidities, to support referrals to the psychological wellbeing clinic
6network for use in selected RACFs. This will assist GPs, other primary care
clinicians and residents to make informed treatment choices to improve the
targeting of psychological interventions within an explicit shared decision-
making framework.
A standardised intake comprehensive process will also be aimed at building
capacity and capability in general practice to identify and support people with
or at risk of mental illness who are living in RACFs, and to utilise appropriate
care pathways and referral processes to services that are tailored to meet the
mental health and wellbeing needs of residents.
A priority of this activity is to ensure that residents of identified RACFs can
receive a comprehensive initial assessment. This will ensure that the identified
treatment options are proportionate to need and can be aligned, discussed and
decided upon within a shared decision-making approach with a resident and
their family – thereby, reducing treatment burden and improving therapeutic
and other benefits. This activity recognises the central role that GPs have in
guiding and supporting treatment decisions for people living in RACFs, that not
only consider potential benefits and risks, but also the values, circumstances
and preferences of residents.
Description of This activity aligns the assessment guidance in Psychological Treatment
Activity Services for people with mental illness in RACFs with the more detailed
requirements of the initial clinical assessment and referral guidance. A
standardised assessment process will be undertaken by suitably qualified and
supervised practitioners, for residents referred with, or at risk of, mental
illness, particularly depression and anxiety.
Work will be undertaken to develop and implement the standardised intake
assessment through a staged project management approach, building upon the
learnings and evaluation results from the first phase/trial of the roll out of
psychological treatment services in RACFs.
The activity is targeted at individuals who:
• live in a RACF
• present as mildly depressed or anxious, but do not have a diagnosis or, are
having trouble adjusting to changes / transitioning or coping with grief
Target population
and/or loss
cohort
• have a former or new diagnosis of mild to moderate mental illness
• have a diagnosis of severe mental illness, which is episodic in nature, may
include pre-existing conditions, and is not being managed by Older Adult
Mental Health Services.
Indigenous specific No
Coverage Perth North PHN
The Perth North PHN will continue to engage and consult with a range of key
stakeholders to effectively develop a standardised assessment process linked
to treatment options for residents of RACFs.
A comprehensive consultation process will be undertaken through a range of
Consultation methods, including face to face, group sessions and online platforms to obtain
information from, and keep stakeholders informed of the progress and
outcomes of the project.
Stakeholder consultation and engagement will occur with:
7• GPs working in RACFs
• nurse practitioners
• Royal Australian College of General Practice
• Consumer and Carer Peak Bodies and Consumer Associations
• Council on the Ageing WA
• Leading Age Services Australia
• RACFs where indicated
• Psychological service providers and PHN commissioned service providers
• Older Adult Mental Health Services
• clinical and academic experts.
The Perth North PHN will work with key stakeholders to plan and co-design and
implement a viable, sustainable and practical solution that meets the identified
needs, priorities and objectives of the project group for an effective initial
comprehensive assessment process for RACFs. This work will be undertaken in
collaboration with similar activities being planned for metropolitan RACFs as
detailed in the WA Country PHN and Perth South PHN Activity Work Plans.
The role of key stakeholder will include:
• Older Adult Mental Health Services who will support to strengthen regional
Collaboration strategic partnerships and provide information and clarity regarding
transition points to and from state based older adult mental health services
• psychological service providers and PHN commissioned service providers
who will work together to design and implement an effective process
• GPs and HealthPathways clinical editors who will assist in the scoping of
the design and implementation of the initial standardised assessment
process
• community and consumer groups who will enhance the PHNs
understanding of the consumer needs and desired consumer experience.
Activity start date: 1/07/2019
Activity end date: 30/06/2021
Service delivery start date: July 2021
Service delivery end date: June 2021
It is envisaged that the key milestones will be:
• the recruitment of an external project consultant to scope/plan the initial
project specification
Activity milestone • the completion of a project plan outlining workstreams with detailed
details/ Duration timelines including:
o completion of consultation and engagement activities
o formulation of process
o development of change management plan
o implementation of change management activities / processes
o development of framework to assess the process’s impacts and
efficacy
o implementation of the completed intake and assessment process.
Commissioning 1. Please identify your intended procurement approach for commissioning
method and services under this activity:
approach to ☒ Not yet known
market 2a. Is this activity being co-designed?
8Yes
2b. Is this activity this result of a previous co-design process?
No
3a. Do you plan to implement this activity using co-commissioning or joint-
commissioning arrangements?
No
3b. Has this activity previously been co-commissioned or joint-commissioned?
No
No
Decommissioning
This activity does not include any decommissioning of services.
Yes
Data collection This activity is in scope for data collection under the Mental Health National
Minimum Dataset.
Total Planned Included in Operational/Administrative funding. Please refer to Funding Source
Expenditure table under MH1.01a.
Proposed Activities
Mental Health Priority area 7: Stepped care approach
Priority Area
MH1.02: Classifying Services to Align with the Initial Clinical Assessment
ACTIVITY TITLE Domains and Target Population (MH1.01a) within a virtual directory
Existing, Modified, New Activity
or New Activity
PHN Program Key Mental Health
Priority Area
Priority:
• PNMH 2.8 Build capacity with General Practice to recognise and support
Needs Assessment patients with mental health conditions and ensure General Practitioners
Priority are aware of appropriate clinical pathways and referral processes. (p.91)
No suitable option available.
The draft guidance for initial clinical assessment identifies two principal
assessment domains, medical complexity and personal context, each with four
sub-domains that should be assessed to identify the service(s) that are best
able to meet individual need (from self-care to secondary care). To achieve this,
available services need to be mapped to the domain and sub-domain
assessment outputs of the standardised intake assessment to provide
appropriate treatment options (considering medical complexity) and associated
Aim of Activity treatment support (considering personal context). Whilst some services are
associated with a single type and level of care, most services contribute to
multiple levels and/or types of care. Through classification, more effective
matching of services and populations groups can occur to meet the needs of
individuals and enhance the shared decision making with a person’s GP.
The aim of the classification of services is to develop sub-regional service maps
that specify available treatment and care options within the stepped-care
9strata (low, moderate, high intensity) and are aligned with the MH1.01
assessment domains, as well as other relevant groupings (age, gender, etc.).
This activity will aim to improve care pathways, provide a more seamless
continuum of care that is flexible and responsive to individuals’ needs, and
build capability in primary care to align the right care, at the right time and in
the right place. This includes the facilitation of self-management (where viable
and appropriate) through the incorporation of voluntary associations within
the service support aspects of the framework.
To ensure the initial assessment has real world utility for clinicians and the
target population it needs to be linked to services than can support the
treatment decisions that follow. To enable this, it is necessary to develop a
directory of locally-based and locally-available services (both physically and
virtually present) that can meet the identified needs.
Potential solutions will be explored during 2019-20 in terms of feasibility, cost-
benefit, utility, likely user acceptance and other criteria. In 2020-21 an initial
Description of version of the service directory will be developed as a working prototype that
Activity can be user tested and iteratively improved by incorporating new information,
where available. Implementation will occur in 2021-22.
Among the options to be considered will be the development of an Application
Program Interface solution enabling service specifications from a variety of
existing directories to be drawn in to interactively populate a new directory.
This will be contrasted with other options such as the development and
maintenance of a new purpose-built directory. This activity is linked to
MH1.01a & MH1.04.
This activity will be targeted at those who are:
• at risk of, or with mild to moderate mental illness, and, in some
circumstances, severe mental illness who can be most appropriately
managed in primary care
• from an underserviced population
• unable to equitably access MBS treatments due to a overlapping factors
indicating disadvantage, including:
Target population
o low income or inability to access services during business hours
cohort
o job insecurity
o material disadvantage
o limited personal resources
o social isolation
o poor health literacy
o other social, economic, cultural and personal reasons
• experiencing locational disadvantage.
Indigenous specific No
Coverage Perth North PHN
The PHN will continue to engage and consult with a range of key stakeholders
to develop a detailed and practical service typology.
Consultation The process will be used to outline the proposed purpose of the service
directories, determine the services in each region that are available in each
care profile, and establish an agreed common language to describe the
services. Information regarding referral pathways and the detail and level of
10mapping to be undertaken will also be addressed during the consultation and
engagement activities.
The following services will be consulted as part of this activity:
• mental health service providers and community services organisations
• North Metropolitan Health Service
• East Metropolitan Health Service
• Women and Newborn Health Service
• WA Mental Health Commission
• Children and Adolescent Health Service
• Aboriginal Community Controlled Health Services
• volunteer organisations and associations.
The consultation and engagement activities will be conducted through a range
of methods including face-to-face and group sessions, and online platforms.
The Perth North PHN will continue to build on existing relationships with key
stakeholders to strengthen and consolidate regional collaboration and
cooperation in planning and delivering mental health care services.
Collaboration will occur with:
Collaboration • PHN commissioned providers and mental health service providers who will
assist to determine service scope and specifications delivered.
• GPs and clinical editors who will provide recommendations regarding how
best to present the information so that it is easily used and portable.
• My Community Directory and the WA Mental Health Commission Directory
to determine how best to utilise information resources already available.
Activity start date: 1/07/2019
Activity end date: 30/06/2022
Service delivery start date: July 2021
Service delivery end date: June 2022
Activity milestone It is envisaged that the key milestones will be:
details/ Duration
• completion of engagement and consultation
• collection of available and relevant service information
• development of service typology
• creation of Application Program Interface data platform
• user testing of the service directories.
1. Please identify your intended procurement approach for commissioning
services under this activity:
☒ Not yet known
2a. Is this activity being co-designed?
Commissioning Yes
method and 2b. Is this activity this result of a previous co-design process?
approach to
No
market
3a. Do you plan to implement this activity using co-commissioning or joint-
commissioning arrangements?
No
3b. Has this activity previously been co-commissioned or joint-commissioned?
11No
No
Decommissioning
This activity does not include any decommissioning of services.
No
Data collection This activity is not in scope for data collection under the Mental Health
National Minimum Dataset.
Total Planned Included in Operational/Administrative funding. Please refer to Funding Source
Expenditure table under MH1.01a
Proposed Activities
Mental Health Priority area 7: Stepped care approach
Priority Area
MH1.03a: Preliminary exploration on the establishment of a Streamlined
ACTIVITY TITLE Referral Process for the Provision of Specialist Bulk Billed Consultation under
MBS
Existing, Modified, New Activity
or New Activity
PHN Program Key Mental Health
Priority Area
Priority:
• PNMH 2.3. Increase access to early intervention services to prevent
escalating acuity and reduce the burden on acute and emergency
department services. (p.88)
Possible Option:
• Support integrated online, telehealth and face to face services i.e. online
Needs Assessment and telehealth services. (p.88)
Priority Priority:
• PNMH 2.4 Increase access to low cost- local mental health services in
outer-suburbs and areas with limited service availability but high demand.
(p.88)
Possible Option:
• Support integrated online, telehealth and face to face services i.e. online
and telehealth services. (p.88)
The aim of the establishment of a streamlined referral process to specialist
services is to improve and increase access to bulk-billed MBS funded consultant
specialist services such as a psychiatrist (including telehealth) for initial
assessment, consultations, and reviews, for patients with or at risk of
developing mental illness who can be appropriately managed in primary care
Aim of Activity by a GP.
The development of this process particularly for individuals with multi-
morbidities, is aimed at providing accessibility to, and support for decisions in
instances where very specific clinical knowledge is required that is outside of
the core primary care health team.
12This activity will support GPs to manage more complex patients in a primary
care setting by providing a single point of referral for accessing specialist
support under MBS.
This activity will establish a streamlined referral process to a consultation
system of expert clinical professionals, bulk-billed under MBS. This will involve
the development and incremental implementation of an effective and efficient
referral pathway/s no matter the location of the referring GP, and the
Description of assembling of a consultancy of specialists who can provide advice, guidance
Activity and support to GPs where indicated.
The ability to avail specialist services through a straightforward process at no
cost to the individual, will ensure the effective management in primary care of
people with more complex and severe mental illness and/or multi-morbidities
where indicated, or referral to acute or state-based care when required.
This activity will be targeted at those who are:
• in most cases with a moderate mental illness, and, in some circumstances,
severe mental illness who can be most appropriately managed in primary
care
• from an underserviced population
• are unable to equitably access MBS treatments due to overlapping factors
indicating disadvantage, including:
o low income or inability to access services during business hours
Target population
o job insecurity
cohort
o material disadvantage
o limited personal resources
o social isolation
o poor health literacy
o other social, economic, cultural and personal reasons
• experiencing locational disadvantage
• who require additional assessment and/or support outside of that readily
accessible in primary care settings.
Yes
MBS item 288, which includes referrals from AMSs and ACCHOs is in scope for
Indigenous specific this activity.
Noting that there will be Indigenous specific components to this activity but
also non-indigenous individuals are in scope and will also benefit.
Coverage Perth North PHN
The PHN will continue to engage and consult with a range of key stakeholders
to build trusting relationships that will result in shared ownership and common
understanding. Consultation and engagement activities will be conducted
through a range of methods including face-to-face and group sessions, and
online platforms.
Consultation Stakeholder consultation and engagement will occur with:
• interested specialists e.g. psychiatrists in private practice
• GPs
• WA Mental Health Commission
• North Metropolitan Health Service
• East Metropolitan Health Service
13• Child and Adolescent Health Service
• Women and Newborn Health Service
• Aboriginal Health Council of WA
• consumer and carer peak bodies.
To design and implement an effective specialist referral process, the Perth
North PHN will identify and involve the key stakeholders and organisations who
will utilise, or have the capacity to influence, its operations.
Activities will involve working with key stakeholders such as specialists to
secure their buy-in to provide their consultancy and cultivate collaboration in
the process’s development.
The role of the key stakeholders will be as follows:
• interested specialists who will provide clarity regarding role definition and
Collaboration scoping of the process and the consultancy service parameters.
• GPs who will assist to determine the support required and scoping of a
streamlined and transparent referral process.
• representative professional bodies who will provide clarity of how the
process will be aligned with other similar processes and with professional
standards.
• North Metropolitan Health Service, East Metropolitan Health Service and
the WA Mental Health Commission who will contribute information and
clarity regarding transition points into state based mental health services.
Activity start date: 1/07/2019
Activity end date: 30/06/2022
It is envisaged that the key milestones for this activity will be:
• recruitment of an external project consultant to scope and plan the initial
project specification
• completion of a project plan outlining workstreams with detailed timelines
Activity milestone including:
details/ Duration
o completion of consultation and engagement activities
o agreement with an organisation to manage the empanelment of
specialists
o development of a referral pathway to specialist services
o development of framework to assess the pathway’s impacts and
efficacy.
1. Please identify your intended procurement approach for commissioning
services under this activity:
☒ Not yet known
2a. Is this activity being co-designed?
Commissioning
method and No
approach to 2b. Is this activity this result of a previous co-design process?
market No
3a. Do you plan to implement this activity using co-commissioning or joint-
commissioning arrangements?
No
143b. Has this activity previously been co-commissioned or joint-commissioned?
No
Decommissioning No This activity does not include any decommissioning of services.
Yes
Data collection This activity is in scope for data collection under the Mental Health National
Minimum Dataset.
Total Planned Included in Operational/Administrative funding. Please refer to Funding Source
Expenditure table under MH1.01a.
Proposed Activities
Mental Health Priority area 7: Stepped care approach
Priority Area
MH1.03b: Preliminary exploration on the establishment of a Streamlined
ACTIVITY TITLE Referral Process for the Provision of Specialist Bulk Billed Consultation under
MBS for Residential Aged Care Facilities
Existing, Modified, New Activity
or New Activity
PHN Program Key Mental Health
Priority Area
Priority:
• PNMH 2.10 Support the mental health of older people and assist primary
care providers to identify older people who may need additional support or
Needs Assessment referrals to services. (p.92)
Priority
Possible Option:
• Work with local communities and service providers to support services that
address identified need. (p.92)
The aim of the establishment of a streamlined referral process to bulk-billed
MBS funded consultant specialist services is to improve and increase access for
residents in RACFs with or at risk of developing mental illness. Services may
include specialist older adult psychiatrist or geriatrician (including telehealth
specialist services) for initial assessment, consultations, medication
Aim of Activity management plans and reviews.
This process is also aimed at providing integrated and coordinated pathways
for residents with multi-morbidities who require specialist care. Further, to
negate any duplication with Older Adult Mental Services, the Perth North PHN
will aim to work with the service to establish a clear and streamlined process
that provides a continuum of care for the resident.
This activity will establish a streamlined referral process for GPs for the
Description of provision of specialist consultation by a specialist bulk-billed under MBS. This
Activity will involve the development and implementation of an effective and efficient
referral pathway/s no matter the location of the referring GP, and the
assembling of a consultancy of specialists who can provide advice, guidance
15and support to GPs where indicated related to residents with or at risk of
mental illness in a RACF.
The ability to avail specialist services through a straightforward process at no
cost to the individual, will ensure the effective management of residents with
multi-morbidities (and associated poly-pharmacy) or referral to state-based
services when indicated.
The activity is targeted at individuals who:
• live in a RACF
• present as mildly depressed or anxious, but do not have a diagnosis or, are
Target population having trouble adjusting to changes / transitioning or coping with grief
cohort and/or loss
• have a former or new diagnosis of mild to moderate mental illness
• have a diagnosis of severe mental illness, which is episodic in nature which
may include pre-existing conditions, and who is not being managed by
Older Adult Mental Health Services.
Indigenous specific No
Coverage Perth North PHN
The PHN will continue to engage and consult with a range of key stakeholders
to build trusting relationships that will result in shared ownership and common
understanding of the anticipated purpose and scoping of the consultancy.
Consultation and engagement activities will be conducted through a range of
methods including face-to-face and group sessions, and online platforms.
Stakeholder consultation and engagement will occur with:
Consultation • interested specialists e.g. older adult psychiatrists in private practice
• GPs
• Older Adult Mental Health Service
• North Metropolitan Health Service
• East Metropolitan Health Service
• selected RACFs
• representative professional bodies
• clinical and academic experts.
To establish an effective streamlined referral process to specialist MBS funded
services for residents of RACFs, the Perth North PHN will collaborate with a
diverse mix of stakeholders to inform decisions around the design and
implementation of the process, and to agree upon the necessary steps required
to underpin its establishment.
The role of the key stakeholders will be:
• interested specialists who will assist to provide clarity regarding role
Collaboration definition and scoping of the process and the consultancy service
parameters.
• GPs who will assist to determine the support required and scoping of a
streamlined and transparent referral process.
• Older Adult Mental Health Services who will assist to provide clarity
regarding transition points into state based mental health services and
strategies to negate duplication.
• RACFs who will provide information on access points and ease of use of a
referral process to specialist services for residents.
16Activity start date: 1/07/2019
Activity end date: 30/06/2021
It is envisaged that the key milestones for this activity will be:
• recruitment of an external project consultant to scope/plan the initial
project specification
• completion of a project plan outlining workstreams with detailed timelines
Activity milestone
including:
details/ Duration
o completion of consultation and engagement activities
o agreement with an organisation to develop an empanelment of
specialists.
o development of a referral pathway to specialist services
o development of framework to assess the pathway’s impacts and
efficacy.
1. Please identify your intended procurement approach for commissioning
services under this activity:
☒ Not yet known
2a. Is this activity being co-designed?
Yes
Commissioning
method and 2b. Is this activity this result of a previous co-design process?
approach to No
market 3a. Do you plan to implement this activity using co-commissioning or joint-
commissioning arrangements?
No
3b. Has this activity previously been co-commissioned or joint-commissioned?
No
No
Decommissioning
This activity does not include any decommissioning of services.
Yes
Data collection This activity is in scope for data collection under the Mental Health National
Minimum Dataset.
Total Planned Included in Operational/Administrative funding. Please refer to Funding Source
Expenditure table under MH1.01a.
Proposed Activities
Mental Health Priority area 7: Stepped care approach
Priority Area
ACTIVITY TITLE MH1.04: Establishment of a Service Model Framework for Perinatal Women
Existing, Modified, New Activity
or New Activity
PHN Program Key Mental Health
Priority Area
17Priority:
• CMHP 2.6 Increase access to mental health specific services to support
women and mothers with babies. (p.89)
Possible Options:
• Provide support and education to general practice to identify women at
risk of perinatal mental health issues. (p.89)
• Partner and collaborate with local communities and service providers to
Needs Assessment support services that support the health and wellbeing of women.
Priority
Priority:
• PNMH 2.3 Increase access to early intervention services to prevent
escalating acuity and reduce the burden on acute and emergency
department services. (p.88)
Possible Option:
• Support short-term, low intensity services for vulnerable people with mild
or moderate mental health conditions. (p.88)
The aim of this activity is to establish a service model framework that provides
evidence-based early intervention services for perinatal mothers, who are
experiencing mild to moderate anxiety and/or depression, and who can be
appropriately managed in primary care.
This activity aims to identify service gaps in order to develop an easily
accessible and mainstream evidence-based short-term psychological
intervention model for children and perinatal mothers, to enhance mental
health and wellbeing during this vulnerable developmental stage of life.
The establishment of a service model will provide:
Aim of Activity • diagnostic support to GPs and other clinicians such as community health
nurses and school psychologists, using the referral pathways developed to
access MBS bulk-billed specialists as per MH1.03a
• short-term evidence-based, structured low intensity and psychological
therapy services as per MH2 and MH3.
By establishing a service model framework for this target group, individuals will
be able to obtain improved access to free, culturally suitable early intervention
services that aim to prevent the escalation of acuity, reduce unnecessary
emergency department presentations, and support GPs to better detect and
manage child and maternal perinatal mental health issues.
Evidence indicates that maternal perinatal mental health, particularly among
women experiencing disadvantage, impacts a child’s emotional behavioural
development and that mental health inequalities widen as children commence
school.i Therefore, the development of an integrated, holistic and multimodal
service model that recognises the higher rates of mental disorders in families
Description of experiencing multiple drivers of disadvantage, and affords additional forms of
Activity treatment support to ameliorate them, is integral to this activity.
This activity will involve the establishment of a viable and appropriate early
intervention service model framework that addresses the needs of perinatal
mothers with, or at risk of, anxiety and/or depression. The service model
framework will be established using a co-design approach involving selected
GPs and the Women and Newborn Health Service.
18It is envisioned that the proposed service model will include the provision of
evidence based early intervention low intensity and psychological therapy
services (as per MH2 and MH3). Part of the establishment of the service model
will also be in identifying and forming partnerships with stable and existing
service centres that are accessed by perinatal women. This will be to improve
access and utilisation of the service, particularly those from underserviced
groups, and to reduce stigmatisation by integrating mental health services
within general health care. Central to the model will be referrals to the new
service from GPs, psychiatrists or paediatricians, as well as those facilitated by
relevant healthcare clinicians such as community child health nurses. It is
envisioned that the service model will be delivered by suitably skilled and
qualified health professionals, including clinical psychologists, mental health
competent registered psychologists, occupational therapists, social workers,
and registered nurses.
The service model framework will also be aligned to the initial intake and
assessment activity (as per MH1.01a) to help determine the intensity of care
required and to inform referral decisions.
It is envisioned that once established, the service model framework will be
piloted in one region of the Country WA PHN to assess its viability, integrity and
sustainability.
i
Rutherford C, Sharp H, Hill J, Pickles A, Taylor-Robinson D (2019) How does perinatal
maternal mental health explain early social inequalities in child behavioural and
emotional problems? Findings from the Wirral Child Health and Development Study.
PLoS ONE 14(5): e0217342. https://doi.org/10.1371/journal. pone.
The activity is targeted at individuals who are:
• perinatal women
• from an underserviced group
• unable to equitably access MBS treatments due to overlapping factors
indicating disadvantage, including:
o low income or inability to access services during school / business
hours
Target population
o job insecurity
cohort
o material disadvantage
o limited personal resources
o social isolation
o poor health literacy
o other social, cultural, spiritual, economic, cultural and personal
reasons
• experiencing locational disadvantage.
Indigenous specific No
Coverage Perth North PHN
Consultation and engagement activities will be undertaken to facilitate
information exchange, explore collaborative opportunities and mitigate the risk
of gaps or duplication in the provision of existing services for this target group.
The Perth North PHN will consult in the first instance with:
Consultation • GPs and nurse practitioners
• Royal College of General Practice
• Consumer and Carer Peak Bodies and Consumer Associations
• Aboriginal Advisory Groups
• Women and Newborn Health Service
19• PHN commissioned service providers of services for this target group
• Emerging Minds
• Department of Education WA
• Metropolitan Clinical Councils
• Telethon Kids Institute
• clinical and academic experts
The consultation and engagement activities will be conducted through a variety
of methods including face-to-face and group sessions, and online platforms.
The Perth North PHN will continue to build on existing relationships with
stakeholders to co-design the service model framework. Collaboration will be
vital in determining roles, responsibilities, and likely outcomes of the co-design
framework.
The role of key stakeholders will be as follows:
Collaboration • GPs and clinical editors who will make recommendations regarding scope
of the design and implementation of the service.
• Women and Newborn Health Service who will assist to strengthen regional
strategic planning and seek input regarding service needs and
implementation strategies.
• PHN commissioned providers who will provide input regarding decisions
about its design and implementation.
Activity start date: 1/07/2019
Activity end date: 30/06/2022
Service delivery start date: July 2020
Service delivery end date: June 2022
It is envisaged that the key milestones will be:
Activity milestone • recruitment of an external project consultant to scope/plan the initial
details/ Duration project specification
• completion of a project plan outlining workstreams with detailed timelines
including:
o completion of consultation and engagement activities
o development of a Co-design Steering Committee
o development of a service model framework
o procurement of services to pilot the service model framework.
1. Please identify your intended procurement approach for commissioning
services under this activity:
☒ Not yet known
2a. Is this activity being co-designed?
Commissioning Yes
method and 2b. Is this activity this result of a previous co-design process?
approach to No
market 3a. Do you plan to implement this activity using co-commissioning or joint-
commissioning arrangements?
No
3b. Has this activity previously been co-commissioned or joint-commissioned?
No
No
Decommissioning
This activity does not include any decommissioning of services
Data collection Yes
20This activity is in scope for data collection under the Mental Health National
Minimum Dataset.
Total Planned Included in Operational/Administrative funding. Please refer to Funding Source
Expenditure table under MH1.01a
Proposed Activities
Mental Health Priority area 6: Aboriginal and Torres Strait Islander mental health services
Priority Area
MH1.05 Establishment of Patient Navigators to support individuals overcome
ACTIVITY TITLE barriers to accessing PHN commissioned treatment services
New Activity
Existing, Modified, This is the continuous service improvement and review of service delivery
or New Activity models for PHN commissioned treatment services. Not the actual
commissioned services.
PHN Program Key Mental Health
Priority Area
Priority:
• PNMH 2.3 Increase access to early intervention services to prevent
escalating acuity and reduce the burden on acute and emergency
department services. (p.88)
Possible Option:
• Support short-term, low intensity services for vulnerable people with mild
or moderate mental health conditions. (p.88)
Priority:
• PNMH 2.5 Support mental health care providers to adopt culturally
Needs Assessment
appropriate models of care for culturally and linguistically diverse groups.
Priority
(p.89)
Priority:
• PNA 4.1 Assist Primary Health Care Providers to adopt culturally
appropriate models of care for Aboriginal populations, Culturally and
Linguistically Diverse groups. (p.98)
Possible Option:
• Support general practices and Aboriginal Community Controlled Health
Organisations to refer Culturally and Linguistically Diverse groups to
identified culturally appropriate services. (p.89)
The aim of this activity is to establish a patient navigators service designed to
support and assist individuals to overcome barriers to accessing available PHN
commissioned mental health care services. This will facilitate patients’
transitions into and out of primary mental health care services, create
Aim of Activity efficiencies in care integration and coordination, and ensure that a patient’s
individualised mental health treatment and treatment support needs (as per
MH1.01a) are adequately met. Ultimately, the patient navigators will aim to
provide a more seamless and patient-centred level of care, that encompasses a
clearer navigation of the primary mental health care system.
21The establishment of patient navigators will also aim to reduce the broader
impact of mental illness in underserviced groups such as Aboriginal and Torres
Strait Islander and CaLD communities, by improving timely access to evidence-
based treatments, as well as building capacity and capability in the sector to
address material and immaterial factors that reduce equitable access to care.
These will include cultural appropriateness, disability access and inclusion, and
contextual environmental, social and economic factors.
Patient navigators will:
• Establish links with local communities to promote access to, and utilisation
of, commissioned mental health services
• Provide information, and practical assistance where indicated, to support
individuals to access, attend and complete recommended treatment
(within the context of an agreed episode of care)
• Identify both the barriers and solutions to the delivery of contextually
appropriate commissioned mental health services
• Facilitate communication between the patient, family members, and
commissioned providers to ensure patient satisfaction and understanding
of their treatment regime
• Support and address cultural, language and spiritual needs where
indicated, for individuals accessing commissioned mental health services
• Advocate to, and work with commissioned providers to provide flexible and
tailored services to meet individual’s needs and goals.
This activity aligns closely with Action Area Three of the National Strategic
Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and
Social and Emotional Wellbeing 2017-2023i (the Framework) which seeks to
build capacity and resilience in people and groups at risk. A key strategy within
Action Area Three is to support access to cultural liaison officers and language
interpreters.
Services will be delivered by locally based and specified navigators who are
suitably trained (Certificate III or IV level) to facilitate access to low intensity
services or psychological therapies, address barriers, and assist individuals with
health literacy and practical and functional challenges. It is envisaged that
services available will include a variety of navigators to meet patients’ needs,
Description of
such as a peer worker or a cultural navigator, in areas where there is a
Activity
significant population of people from Aboriginal and Torres Strait Islander
backgrounds or who are Culturally and Linguistically Diverse (CaLD), or other
target populations where appropriate.
The establishment of patient navigators presents an opportunity for the Perth
North PHN commissioned services to deliver culturally appropriate care as a
core activity of the service delivery model without this being a cost to the core
treatment activity. The Perth North PHN will utilise the Aboriginal and Torres
Strait Islander Suicide Prevention (ATSISPEP) Framework, PHN Aboriginal
mental health co-design reportsii and other key policy to inform commissioned
providers application of the service and how activity will be reported,
measured and evaluated. It is envisaged that the percentage of uncompleted
22episodes of care and unattended appointments, and the ensuing service costs,
will be reduced.
i
Commonwealth of Australia 2017. National Strategic Framework for Aboriginal and
Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing .
Canberra: Department of the Prime Minister and Cabinet.
ii
https://www.wapha.org.au/404-2/
The patient navigator services will be targeted at Aboriginal and Torres Strait
Islander individuals who:
• are at risk of, or living with, mild to moderate mental illness and in some
cases severe mental illness (who can be appropriately managed in primary
care)
• are from an underserviced group
• are unable to equitably access MBS treatments due to overlapping factors
indicating disadvantage, including:
Target population o low income or inability to access services during school / business
cohort hours
o job insecurity
o material disadvantage
o limited personal resources
o social isolation
o poor health literacy
o other social, cultural, spiritual, economic, cultural and personal
reasons
• experience locational disadvantage.
Indigenous specific Yes
Coverage Perth North PHN
Consultation and engagement activities will be undertaken through a range of
methods including face to face and group sessions, and web-based platforms to
inform key stakeholders about the patient navigation service, and to
understand their aspirations and explore their local needs.
The Perth North PHN will consult with:
• PHN commissioned service providers
• GPs
Consultation
• Aboriginal Health Council of WA
• Aboriginal Community Controlled Health Organisations
• selected Elders and community leaders
• Ethnic Community Council of Western Australia
• Multicultural Services Centre WA
• relevant community, consumer and carer advisory groups and associations
• clinical and academic experts.
The Perth North PHN will collaborate with the following key stakeholders:
• PHN commissioned service providers who will assist to determine the
cultural navigation services required to support access to, and use of,
Collaboration commissioned treatment, and
• selected local communities/Elders/consumers who will assist to identify
key cultural barriers that limit access and utilisation of commissioned
mental health services.
23Activity start date: 1/07/2019
Activity end date: 30/06/2021
It is envisaged that the key milestones for this activity will be:
• recruitment of an external Project Consultant to scope / plan the initial
project specification
Activity milestone • completion of a project plan outlining workstreams with detailed timelines
details/ Duration including:
o completion of consultation and engagement activities
o definition of the roles and responsibilities of the expected role
o development of framework to assess the activities impacts on referral
rates and treatment completion
o development of a procurement plan for the activity.
1. Please identify your intended procurement approach for commissioning
services under this activity:
☒ Not yet known
2a. Is this activity being co-designed?
Yes
Commissioning
2b. Is this activity this result of a previous co-design process?
method and
approach to No
market 3a. Do you plan to implement this activity using co-commissioning or joint-
commissioning arrangements?
No
3b. Has this activity previously been co-commissioned or joint-commissioned?
No
No
Decommissioning
This activity does not include any decommissioning of services.
Yes
Data collection This activity is in scope for data collection under the Mental Health National
Minimum Dataset.
Total Planned Included in Operational/Administrative funding. Please refer to Funding Source
Expenditure table under MH1.01a.
Proposed Activities
Mental Health Priority area 3: Psychological therapies for rural and remote, under-serviced
Priority Area and / or hard to reach groups
MH1.06: Establishment of a Psychological Wellbeing Clinic Network for
ACTIVITY TITLE Residential Aged Care Facilities
Existing, Modified, New Activity
or New Activity
PHN Program Key Mental Health
Priority Area
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