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International Journal of Mental Health Nursing (2015) 24, 75–81
doi: 10.1111/inm.12099
Feature Article
Impact of the Mental Health Nurse Incentive Programme on patient functioning Tom Meehan1 and Samantha Robertson2 1
Centre for Mental Health, University of Queensland & The Park, and 2Queensland University of Technology, Brisbane, Queensland, Australia
ABSTRACT: The Mental Health Nurse Incentive Programme (MHNIP) was established across Australia during 2007. The programme enables mental health nurses to work alongside general practitioners (GPs) and other health professionals to assist in the assessment and treatment of people with mental illnesses. This paper reports on the outcomes for 309 patients referred by GPs to the programme in one region of Queensland. Standardized measures were completed pre- and post-treatment to evaluate changes in symptoms and general functioning between baseline and follow up. Patient contact with the programme ranged from 3 weeks to 38 weeks, and the study group (n = 84) demonstrated significant improvement on all of the self-report and clinician-rated measures employed. Effect sizes ranged from 0.59 to 0.74. The findings suggest that the MHNIP is making a positive contribution, with a medium-to-large impact on the mental health and general functioning of individuals supported through the programme. Further evaluation work is required to determine if the findings from this study can be generalized more broadly. KEY WORDS: evaluation, Mental Health Nurse Incentive Programme, outcome, standardized measure.
INTRODUCTION The National Action Plan on Mental Health 2006–2011 promoted better integration of primary care and specialist mental health services for those with severe mental conditions (Council of Australian Governments 2006). The increasing demands being placed on general practitioners (GPs) and other primary health providers to improve the outcomes for those with mental illnesses were recognized. In July 2007, the Mental Health Nurse Incentive Programme (MHNIP) was one of the initiatives introduced across Australia to improve access to primary care for those with severe and persistent mental illnesses.
Correspondence: Tom Meehan, Centre for Mental Health, University of Queensland & The Park, Locked Bag 500, Richlands, Qld 4077, Australia. Email: [email protected] Tom Meehan, RN, BHSc, MPH, MSocSc, PhD. Samantha Robertson, B.BusComm, BA (Hons). Accepted August 2014.
© 2014 Australian College of Mental Health Nurses Inc.
The programme has a number of broad aims, which focus on: (i) improving the levels of care for people with severe and persistent mental illnesses; (ii) reducing the likelihood of unnecessary admissions and readmissions; (iii) assisting in keeping people with severe illnesses feeling well and connected within the community; and (iv) alleviating pressure on privately-practicing psychiatrists and GPs (Australian Government Department of Health and Aging 2010). The emphasis is on those with severe problems, as there are other Commonwealthfunded programmes available for people with less severe problems (Pirkis et al. 2006). Under the guidelines for the programme, GPs, private psychiatrists, and Aboriginal Medical Services can employ or engage mental health nurses (MHN) to assist with service coordination and treatment for eligible patients (Australian Government Department of Health and Aging 2012). In effect, MHN work in collaboration with GPs (and other service providers) to provide a suite of interventions aimed at enhancing the continuity of patient
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care. These interventions include the planning of patient care, providing periodic reviews of the patient’s mental state, monitoring medication, linking patients to other health professionals, and providing patient services in a range of settings (i.e. GP clinics and patients’ homes). Demand for the programme has steadily increased since it was introduced in 2007. The number of patients receiving treatment through the programme increased from 6998 in the 2007–2008 financial year to 41 535 in the year prior to April 2012 (Senate Community Affairs Committee 2012). Indeed, the overall cost of the programme has increased exponentially from $2.7 million in 2007–2008 financial year to $35.6 million in the 2011–2012 financial year (Senate Community Affairs Committee 2012). Despite the significant expansion of the programme, there has been little published research on the outcomes for programme participants. Most of the published studies thus far have been descriptive and tend to draw conclusions about the outcomes of the programme from the narrative accounts of providers and consumers. Happell et al. (2010) interviewed 10 nurses working with the MHNIP in Queensland. The nurses believed that patients receiving treatment through the programme had lower rates of hospitalization and spent less time in hospital when admission became necessary. In a larger, Australia-wide study, Lakeman (2013) undertook an online survey of 225 credentialed MHN involved with the programme. These nurses believed that MHNIP patients demonstrated a ‘reduction in symptoms and improved coping, improved relationships and greater community participation’ (p. 391). Other common themes included a reduced need for hospitalization, less disruption to occupation, and improved physical health. However, in both of these studies, the findings were based on the perceptions of the nurses involved, rather than objective data derived from recognized measures of outcome. Moreover, therapists are likely to be poor judges of their effectiveness and tend to overrate their ability (Duncan 2012). Feedback from consumers has been positive, with overwhelming support for the programme. Happell and Palmer (2010) conducted interviews with 14 consumers in the programme and found that they valued the convenient, holistic, and non-stigmatizing care offered through the programme. However, the evaluation focused more on programme-delivery issues, and there was little information on consumer perceptions of how the programme had helped them. In a similar approach, Meehan and Robertson (2013a) carried out telephone interviews with 19 patients within 6 weeks of been discharged from the programme. While all of the patients agreed that the
T. MEEHAN AND S. ROBERTSON
programme had helped them, details of other outcomes were not discussed. Few studies have focused on the assessment of quantitative outcomes. An evaluation of the programme funded by the Commonwealth Government (Health Management Advisers 2012) supports the positive perceptions of providers and consumers highlighted earlier. The evaluation found that hospital admissions for those enrolled in the programme decreased by 13.3% in the 12 months’ post-programme. Moreover, the average length of stay for those who required admission decreased from 37.2 to 17.7 days, which resulted in an estimated saving of $A2600 per patient. Other flow-on benefits included increased levels of employment and improved family connections. Apart from these data, no other clinical or general functioning data were reported. More recently, Lakeman and Bradbury (2013) conducted an online survey of nurses working with the MHNIP. Completed Health of the Nation Outcome Scales (HoNOS) for 64 people on admission to the programme, and again at final review, were submitted as part of the survey. Statistically-significant reductions on all HoNOS domains, except physical health, were noted. However, the researchers had no control over the patient profiles or data submitted by the nurses. The authors noted that selection bias might have contributed to the wide variation between admission and discharge scores for the client profiles that were submitted. In the present study, we compared pre-/post-clinical and general functioning data for a sample of consecutive patients who received treatment through the MHNIP.
METHOD The present study is part of a larger evaluation of the MHNIP in the Ipswich area of Queensland, Australia. This component of the evaluation focused on the outcomes for clients in the programme, and employed a single group, pre-/post-test design, where the clients were used as their own controls.
Sample All consecutive patients (n = 403), referred by GPs to seven MHN working under the MHNIP in the Ipswich area of Queensland, were invited to participate in the evaluation. Although 309 of the patients (76.6%) were enrolled in the study, follow-up data were available for a subgroup of 84 patients (27.2%). Missing data resulted from 37 patients (11.8%) being referred to psychologists or psychiatrists for ongoing treatment, and this hampered © 2014 Australian College of Mental Health Nurses Inc.
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the collection of follow-up data. Another 20 patients (6.4%) were referred to local mental health services for assessment and treatment. Eighteen other patients (6.1%) did not return for further treatment following the initial assessment, and four patients (1.3%) moved out of the catchment area. While 146 patients remained with the programme, follow-up data were available for 84 of these. The reasons for the relatively high drop-out rate vary, and tend to be either client or context dependent. Some clients dropped out, as their presenting problem had improved, others saw their GP on the final visit, and follow-up measures were not completed. Follow-up contact with some patients was by telephone, rather than in person, which resulted in measures not being completed. Finally, the MHN appeared to be more vigilant in collecting baseline data (rather than the follow-up data), which was collected during the mandatory consent procedures for client entry into the programme.
working with the GP in one of seven GP practices. Details of the evaluation were provided to each patient during the initial meeting with the MHN. Patients agreeing to participate in the evaluation were asked to sign a consent form and complete the self-report measure (DASS-21). Over the next couple of meetings, the MHN completed the clinician-rated measures (HoNOS and GAF). These same measures were completed for a second time when a patient was discharged from the programme or at 6 months’ post-entry into the programme (for those continuing with the programme). As such, there was wide variation in the follow-up period, as patients exited the programme at different time points. The follow-up period ranged from a minimum of 3 weeks to a maximum of 28 weeks (median = 15 weeks). Over this study period, patients received between one and 44 sessions (mean = 8.5, standard deviation (SD) = 18.2) with an MHN.
Measures
Data analysis
Three standardized measures were employed to assess patient well-being on entry into the programme and at follow up. Illness severity was assessed using HoNOS (Wing et al. 1996). The measure has a total of 12 scales, and these assess the severity of psychopathology and physical health over the preceding 2 weeks. Each scale is rated using a five-point Likert format (0–4), with a higher score indicating more severe problems. Emotional states were assessed using the Depression, Anxiety and Stress Scale-21 (DASS-21) (Lovibond & Lovibond 1995). The brief version of the measure contains 21 items, but scores can be doubled to correspond with the larger 42-item version of the measure. The measure has three subscales that focus on depression, anxiety, and stress. The measure is self-rated by the patient using a four-point Likert scale (0–3), with higher scores indicating more severe problems. Finally, overall functioning was assessed using the Global Assessment of Functioning (GAF) scale (Endicott et al. 1976). The measure requires the clinician to make an overall judgment about a patient’s current functioning on a continuum, from superior mental health to profound mental impairment that precludes any social or occupational competency. These ratings are made on a scale of one to 100, and unlike the other measures described earlier, lower GAF scores indicate more severe problems.
Data were cleaned and checked for errors, and analysed using the statistical package SPSS for Windows (version 18; SPSS, Chicago, IL, USA). Items in each measure were rescored in the direction outlined by the developers of the individual measures. Subscale and total scale scores were computed and used in the analysis of data from that point onwards. Descriptive statistics were used to summarize the data. Independent-samples t-tests and χ2 analyses were used to investigate whether there were any significant demographic or clinical differences in those with and without follow-up data. Paired-samples t-tests and effect sizes were used to compare changes in outcomes between baseline and follow up. The probability level was adjusted for the multiple comparisons using the Bonferroni correction to provide an adjusted probability level of 0.01 (i.e. 0.05/5 = 0.01). Cohen’s d was used to estimate the effect size of the outcome, and was calculated by dividing the mean of the difference scores (between baseline and follow up) by the pooled SD of both assessments (Cohen 1987).
Procedure The evaluation was approved by the West Moreton District Ethics Committee. All patients deemed suitable for the MHNIP were referred by their GP to the MHN © 2014 Australian College of Mental Health Nurses Inc.
RESULTS Completed pre-/post-measures were available for 84 of the 309 patients enrolled in the evaluation (27.1%). There was considerable loss of patients from the study, and it is possible that the patients with follow-up data were different in some systematic way from those lost to follow up. To assess this, we compared baseline assessment scores for those with and those without follow-up data. Those with follow-up data were significantly older
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T. MEEHAN AND S. ROBERTSON
Changes in client functioning pre-/post-intervention through MHNIP
(mean = 43.04 years) than those without follow-up data (mean = 35.65 years, t = 3.50, P = 0.001) (Table 1). While differences in total scale scores for both groups did not reach statistical significance, there was a significant difference in the social problems subscale of HoNOS. Those with follow-up data had higher mean scores (more severe problems) on the social problems subscale (t = −2.74, P = 0.006). This subscale contains four scales that assess deficits in relationships, activities of daily living, accommodation, and occupation.
Overall, the study group demonstrated significant improvement on all of the measures at follow up (Table 2). The mean total HoNOS score for the sample decreased (improved) significantly (t = 5.43, P < 0.001), from a mean of 12.01 (SD = 4.7) on entry into the programme to a mean of 9.04 (SD = 4.98) at follow up. Likewise, scores for all three DASS-21 subscales
TABLE 1: Demographic and clinical characteristics of clients with and without follow-up data Baseline for clients with follow-up data (n = 84) Mean (SD)
Variable
Baseline for clients without follow up data (n = 146) Mean (SD)
Age
43.04 (13.53)
35.65 (13.62)
Sex Male Female HoNOS total score
50 (59.52%) 34 (40.48%) 11.96 (4.58)
90 (61.65%) 56 (38.34%) 12.89 (4.73)
GAF
58.08 (11.42)
60.33 (10.57)
DASS-21 – Depression: subscale score
23.76 (12.40)
24.30 (11.48)
DASS-21 – Anxiety: subscale score
17.90 (10.48)
17.70 (11.1)
DASS-21 – Stress: subscale score
25.50 (10.54)
26.08 (10.64)
Statistics t = 3.50 P = 0.001 (χ2 = 0.04, P = 0.83).
t = 1.53 P = 0.12 t = 1.58 P = 0.11 t = 0.38 P = 0.73 t = 0.13 P = 0.89 t = 0.40 P = 0.69
DASS-21, Depression, Anxiety, Stress Scale-21; GAF, Global Assessment of Functioning; HoNOS, Health of the Nation Outcomes Scales; SD, standard deviation.
TABLE 2:
Differences between baseline and follow-up scores for patients enrolled in the Mental Health Nurse Incentive Programme
Measure HoNOS (T1) (T2) GAF (T1) (T2) DASS-21: Depression (T1) (T2) DASS-21: Anxiety (T1) (T2) DASS-21: Stress (T1) (T2)
Mean (SD)
Mean difference (SD)
t-tests (paired samples)
Effect size
12.01 (4.57) 9.04 (4.98)
−2.82 (4.31) (n = 84)
t = 5.43 P < 0.001
0.62
59.22 (10.49) 66.43 (8.92)
7.21 (14.43) (n = 83)
t = −5.46 P < 0.001
0.74
23.24 (11.46) 15.64 (12.96)
−7.60 (12.97) (n = 81)
t = 4.14 P < 0.001
0.63
16.32 (8.25) 10.92 (9.77)
−5.40 (8.98) (n = 82)
t = 3.11 P < 0.003
0.59
24.40 (9.72) 17.80 (11.75)
−6.6 (11.78) (n = 80)
t = 3.93 P < 0.001
0.61
DASS-21, Depression, Anxiety, Stress Scale-21; GAF, Global Assessment of Functioning; HoNOS, Health of the Nation Outcomes Scales; SD, standard deviation; T1, initial assessment (entry into the Mental Health Nurse Incentive Programme); T2, follow-up assessment.
© 2014 Australian College of Mental Health Nurses Inc.
MENTAL HEALTH NURSE INCENTIVE PROGRAMME
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No. admissions
1000 800 600 400 200 0 2004 FIG. 1: Admissions to local acute inpatient unit over study period.
(stress, anxiety, and depression) decreased (improved) significantly between baseline and follow up. Finally, the mean GAF score increased significantly, from 59.22 to 66.43, indicating significant improvement in general functioning (mean difference = 7.21, t = −5.46, P = 0.001). The anchor for the GAF score at follow up indicates that patients had mild symptoms or some difficulty in functioning. Effect size provides a useful means of quantifying the size of the change between two assessments, and emphasizes the clinical usefulness (rather than the statistical significance) of an intervention. Cohen (1987) suggests that effect sizes of 0.20 are small and indicate that a given intervention has negligible clinical importance; values of 0.50 indicate that the programme has moderate clinical importance, and values of 0.80 or more are large and indicate interventions have high clinical importance. In the present study, effect sizes ranged from 0.59 to 0.74 (Table 2). The interventions provided through the MHNIP appeared to have the least impact on anxiety (d = 0.59) and the greatest impact on general functioning (d = 0.74), as measured by the GAF scale.
Admission to acute care since the introduction of the MHNIP Data relating to the number of patients admitted to the Acute Care Unit at Ipswich Hospital between 2004 and 2012 are displayed in Figure 1. These data indicate that admissions to the unit have remained relatively stable since 2008 (when the programme commenced in the Ipswich area). The average number of admissions to the acute unit in the 4 years prior to 2008 was 834 (SD = 48.0), and for the 4 years following 2008, it was 781 (SD = 36.6, t = 1.74, P = 0.13).
DISCUSSION The rapid implementation and expansion of the MHNIP in Australia has hampered attempts to adequately evalu© 2014 Australian College of Mental Health Nurses Inc.
2005
2006
2007
2008
2009
2010
2011
2012
Year
ate its impact (Olasoji & Maude 2010). While the present study adds to our understanding of the programme, it has a number of limitations. The nurses involved were aware of the evaluation aims, and had a vested interest in demonstrating that the programme was effective. They could have unintentionally introduced bias when completing the observer-rated measures (HoNOS, GAF) at follow up, by perceiving their patients in a more positive light (Lakeman & Bradbury 2013). Nonetheless, the DASS-21 measure was completed directly by the patients, and the findings from this also pointed to significant improvements. It is also possible that patients could have improved over time due to the natural course of the illness; they might have improved, even if they did not receive the intervention. In the absence of a control group, some degree of caution is required when attributing the significant outcomes identified to the programme. Like most naturalistic studies, there was considerable loss of clients from the study. While attempts were made to recruit all consecutive patients, only 309 of a possible sample of 403 patients were enrolled in the study. It is clear that some of the MHN involved were more successful at recruiting clients for the evaluation. While one of the nurses enrolled 91% of their clients, another could only recruit 22% of their clients. Notwithstanding this, we secured paired data for 21% of clients, which compares favourably to the 15% of clients with paired data in the national evaluation of the Access to Allied Psychological Services (ATAPS) programme (Pirkis et al. 2010). Future evaluations of the MHNIP should consider recruitment issues, and work more closely with the nurses involved to improve recruitment. Systematic bias might have been introduced through the loss of patients with more severe problems from the programme. However, examination of assessment data at baseline identified few differences in those with/without follow-up data. Nonetheless, those with follow-up data (i.e. those who remained in the programme) were
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significantly older and had more severe problems during initial assessment on the ‘social’ subscale of HoNOS. This subscale assesses four aspects of functioning (relationships, activities of daily living, accommodation and occupation). Lakeman and Bradbury (2013, p. 334) noted that the MHNIP appears ‘to facilitate meeting psychosocial and relational needs’, and as such, patients with social problems might have engaged more fully with the programme. Overall, the MHNIP appears to be targeting patients with severe mental conditions. The mean total HoNOS score for patients in our sample was 12.01 (SD = 4.6) on entry into the programme, which is compared to a mean score of 15.4 (SD = 6.7) for those admitted to hospital (Meehan & Robertson 2013b). The mean of 12.01 is significantly lower than the mean of 21.47 (SD = 7.8) reported by Lakeman and Bradbury (2013) in their national survey. This variation in admission scores points to large clinical differences in the clients treated through the programme. While the completion of HoNOS is mandated for all clients supported through the MHNIP, there is no system in place at the national level to capture and report on these data. In the absence of national summary data, it is difficult to draw conclusions about illness severity in those treated at the different sites. Indeed, Meehan and Robertson (2013b) have recommended a broader range of measures to assess the severity of high-prevalence illnesses (e.g. depression, anxiety), as this would enable direct comparison of outcomes with other similar programmes, such as ATAPS. The present study found highly-significant improvements on all of the domains assessed. The total HoNOS score decreased (improved) significantly, from a mean of 12.01 on entry into the programme to a mean of 9.04 at the point of discharge from the programme. This score is similar to the discharge score of 9.61 reported by Lakeman and Bradbury (2013) in their national sample. This seems to suggest that, despite the disability level on entry into the programme, clients either leave or are discharged from the programme when their HoNOS score decreases to a range of between nine and 10. Participation in the programme also resulted in a significant improvements in emotional states. There were statistically-significant improvements in levels of depression, anxiety, and stress between baseline and follow up. While the change scores were statistically significant, they were also clinically significant. Effect sizes ranged from 0.59 to 0.74. The findings suggest that the MHNIP is making a positive contribution, with a medium-to-large
T. MEEHAN AND S. ROBERTSON
impact on the mental health and general functioning of individuals enrolled in the programme. One goal of the MHNIP is to reduce the need for hospital admission for people with severe mental conditions (Australian Government Department of Health and Aging 2010). A recent evaluation of the MHNIP across Australia showed that hospital admissions for mental illnesses decreased by 13.3% in the 12 months following involvement with the programme (Health Management Advisers 2012). As it proved too difficult in the present study to track patients once they left the programme, we examined admission data for the local inpatient unit. While the average number of admissions to the inpatient unit decreased in the 4 years since the programme commenced, the decrease was not statistically significant. The finding supports earlier UK research, which found that the introduction of a mental health team at a GP clinic did not decrease utilization of inpatient beds or emergency department contacts (Jackson et al. 1993). It is clear that admission to acute inpatient care can be influenced by a number of factors, including the availability of beds. As such, it is possible that the programme did reduce the need for hospital admission in MHNIP patients, but these beds were allocated to other people. It is recommended that future evaluations of the programme establish methods for gathering data on the number of admissions and days spent in hospital pre-/post-engagement with the MHNIP. The findings presented here focus on clinical functioning, and not on functioning more broadly. It is clear from related studies (Health Management Advisers 2012; Meehan & Robertson 2013a) that other indices of functioning, such as employment and quality of life, are also likely to improve due to the MHNIP. Future evaluations should, in addition to clinical functioning, examine these broader (‘non-clinical’) aspects of functioning. Finally, despite the positive outcomes for clients in this and previously-published independent evaluations, the fate of the MHNIP remains unclear. The Australian Government has maintained funding for the 2014–2015 year at 2013–2014 levels, and there is no guarantee that the programme will continue beyond June 2015. It has called for a review of all existing mental health programmes to identify gaps in service provision and ensure that mental health services are not being duplicated (Australian Government Medicare Australia 2009). While this review will focus on process issues, it must also consider the positive evaluation findings and feedback from consumers and providers. © 2014 Australian College of Mental Health Nurses Inc.
MENTAL HEALTH NURSE INCENTIVE PROGRAMME
CONCLUSIONS The MHNIP represents another step in the long road towards mainstreaming mental health services into the general health system. The findings from this evaluation shed light on the outcomes that can be expected from the programme. It is likely that the programme is achieving a positive effect, in the medium-to-large range, for patients with mental illnesses. Should the programme continue to be funded, research is required to determine if the positive findings identified in this evaluation can be applied more broadly. It is recommended that a minimum dataset (focusing on clinical, non-clinical, cost, and demographic data) be developed and implemented to facilitate ongoing evaluation of the programme.
REFERENCES Australian Government Department of Health and Aging (2010). Nurses: Mental Health Nurse Incentive Program. [Cited 23 March 2012]. Available from: URL: http:// www.health.gov.au/internet/main/publishing.nsf/Content/ work-pr-mhnip Australian Government Department of Health and Ageing (2012). Mental Health Nurse Incentive Program. [Cited 15 December 2012]. Available from: URL: http:// www.health.gov.au/internet/main/publishing.nsf/Content/ work-pr-mhnip Australian Government Medicare Australia (2009). Mental health Nurse Incentive Program – Important Notice for MHNIP Service Providers. [Cited 14 July 2014]. Available from: URL: http://www.medicareaustralia.gov.au/provider/ incentives/MHNIP/index.jsp Cohen, J. (1987). Statistical Power Analysis for the Behavioural Sciences. Hillsdale, NJ: Lawrence Earlbraum Associates. Council of Australian Governments (2006). National Action Plan on Mental Health 2006–2011. Canberra: Council of Australian Governments (COAG). Duncan, B. (2012). The Partners for Change Outcome Managed Systems (PCOMS): The heart and soul of change project. Canadian Psychology, 53 (2), 93–104. Endicott, J., Spitzer, R., Fleiss, J. & Cohen, J. (1976). The Global Assessment Scale: A procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry, 33, 766–771. Happell, B. & Palmer, C. (2010). The Mental Health Nurse Incentive Program: Benefits from a client perspective. Issues in Mental Health Nursing, 31, 646–653. Happell, B., Palmer, C. & Tennent, R. (2010). Mental Health Nurse Incentive Program: Contributing to positive client
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81 outcomes. International Journal of Mental Health Nursing, 19, 331–339. Health Management Advisers (2012). Evaluation of the Mental Health Nurse Incentive Program. Department of Health and Aging. [Cited 8 March 2013]. Available from: URL: http:// www.health.gov.au/internet/main/publishing.nsf/Content/ work-pr-mhnip#eva Jackson, G., Gater, R., Goldberg, D., Tantam, D., Loftus, L. & Taylor, H. (1993). A new community mental health team based in primary care. A description of the service and its effects in the first year. British Journal of Psychiatry, 162, 375–384. Lakeman, R. (2013). Mental health nurses in primary care: Qualitative outcomes of the Mental Health Nurse Incentive Program. International Journal of Mental Health Nursing, 22, 391–398. Lakeman, R. & Bradbury, J. (2013). Mental health nurses in primary care: Quantitative outcomes of the Mental Health Nurse Incentive Program. Journal of Psychiatric and Mental Health Nursing, 21, 327–335. Lovibond, S. & Lovibond, P. (1995). Manual for the Depression Anxiety Stress Scales, 2nd edn. Sydney, Australia: Psychological Foundation of Australia. Meehan, T. & Robertson, S. (2013a). The Mental Health Nurse Incentive Program: Reactions of general practitioners and their patients. Australian Health Review, 37, 337–340. Meehan, T. & Robertson, S. (2013b). Clinical profile of people referred to mental health nurses under the Mental Health Nurse Incentive Program. International Journal of Mental Health Nursing, 22, 384–390. Olasoji, M. & Maude, P. (2010). The advent of mental health nurses in Australian general practice. Contemporary Nurse, 31, 106–117. Pirkis, J., Burgess, P., Kohm, F., Morley, B., Blashki, G. & Naccarella, L. (2006). Models of psychological service provision under Australia’s Better Outcomes in Mental Health Care (BoIMHC) program. Australian Health Review, 30, 277–285. Pirkis, J., Bassilios, B., Fletcher, J. et al. (2010). Evaluating the Access to Allied Psychological Services (ATAPS) Component of the Better Outcomes in Mental Health Care (BoIMHC) Program. Melbourne: Centre for Mental Health Policy, Programs and Economics, University of Melbourne. Senate Community Affairs Committee (2012). Health and Aging Portfolio. Answers to Estimates Questions on Notice (Question E12-143). Canberra: Senate Affairs Committee. Wing, J., Beevor, A., Curtis, R., Park, S., Hadden, S. & Burns, A. (1996). Health of the Nation Outcome Scales (HoNOS). Report on research and development. British Journal of Psychiatry, 172, 11–18.
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International Journal of Mental Health Nursing (2015) 24, 75–81
doi: 10.1111/inm.12099
Feature Article
Impact of the Mental Health Nurse Incentive Programme on patient functioning Tom Meehan1 and Samantha Robertson2 1
Centre for Mental Health, University of Queensland & The Park, and 2Queensland University of Technology, Brisbane, Queensland, Australia
ABSTRACT: The Mental Health Nurse Incentive Programme (MHNIP) was established across Australia during 2007. The programme enables mental health nurses to work alongside general practitioners (GPs) and other health professionals to assist in the assessment and treatment of people with mental illnesses. This paper reports on the outcomes for 309 patients referred by GPs to the programme in one region of Queensland. Standardized measures were completed pre- and post-treatment to evaluate changes in symptoms and general functioning between baseline and follow up. Patient contact with the programme ranged from 3 weeks to 38 weeks, and the study group (n = 84) demonstrated significant improvement on all of the self-report and clinician-rated measures employed. Effect sizes ranged from 0.59 to 0.74. The findings suggest that the MHNIP is making a positive contribution, with a medium-to-large impact on the mental health and general functioning of individuals supported through the programme. Further evaluation work is required to determine if the findings from this study can be generalized more broadly. KEY WORDS: evaluation, Mental Health Nurse Incentive Programme, outcome, standardized measure.
INTRODUCTION The National Action Plan on Mental Health 2006–2011 promoted better integration of primary care and specialist mental health services for those with severe mental conditions (Council of Australian Governments 2006). The increasing demands being placed on general practitioners (GPs) and other primary health providers to improve the outcomes for those with mental illnesses were recognized. In July 2007, the Mental Health Nurse Incentive Programme (MHNIP) was one of the initiatives introduced across Australia to improve access to primary care for those with severe and persistent mental illnesses.
Correspondence: Tom Meehan, Centre for Mental Health, University of Queensland & The Park, Locked Bag 500, Richlands, Qld 4077, Australia. Email: [email protected] Tom Meehan, RN, BHSc, MPH, MSocSc, PhD. Samantha Robertson, B.BusComm, BA (Hons). Accepted August 2014.
© 2014 Australian College of Mental Health Nurses Inc.
The programme has a number of broad aims, which focus on: (i) improving the levels of care for people with severe and persistent mental illnesses; (ii) reducing the likelihood of unnecessary admissions and readmissions; (iii) assisting in keeping people with severe illnesses feeling well and connected within the community; and (iv) alleviating pressure on privately-practicing psychiatrists and GPs (Australian Government Department of Health and Aging 2010). The emphasis is on those with severe problems, as there are other Commonwealthfunded programmes available for people with less severe problems (Pirkis et al. 2006). Under the guidelines for the programme, GPs, private psychiatrists, and Aboriginal Medical Services can employ or engage mental health nurses (MHN) to assist with service coordination and treatment for eligible patients (Australian Government Department of Health and Aging 2012). In effect, MHN work in collaboration with GPs (and other service providers) to provide a suite of interventions aimed at enhancing the continuity of patient
76
care. These interventions include the planning of patient care, providing periodic reviews of the patient’s mental state, monitoring medication, linking patients to other health professionals, and providing patient services in a range of settings (i.e. GP clinics and patients’ homes). Demand for the programme has steadily increased since it was introduced in 2007. The number of patients receiving treatment through the programme increased from 6998 in the 2007–2008 financial year to 41 535 in the year prior to April 2012 (Senate Community Affairs Committee 2012). Indeed, the overall cost of the programme has increased exponentially from $2.7 million in 2007–2008 financial year to $35.6 million in the 2011–2012 financial year (Senate Community Affairs Committee 2012). Despite the significant expansion of the programme, there has been little published research on the outcomes for programme participants. Most of the published studies thus far have been descriptive and tend to draw conclusions about the outcomes of the programme from the narrative accounts of providers and consumers. Happell et al. (2010) interviewed 10 nurses working with the MHNIP in Queensland. The nurses believed that patients receiving treatment through the programme had lower rates of hospitalization and spent less time in hospital when admission became necessary. In a larger, Australia-wide study, Lakeman (2013) undertook an online survey of 225 credentialed MHN involved with the programme. These nurses believed that MHNIP patients demonstrated a ‘reduction in symptoms and improved coping, improved relationships and greater community participation’ (p. 391). Other common themes included a reduced need for hospitalization, less disruption to occupation, and improved physical health. However, in both of these studies, the findings were based on the perceptions of the nurses involved, rather than objective data derived from recognized measures of outcome. Moreover, therapists are likely to be poor judges of their effectiveness and tend to overrate their ability (Duncan 2012). Feedback from consumers has been positive, with overwhelming support for the programme. Happell and Palmer (2010) conducted interviews with 14 consumers in the programme and found that they valued the convenient, holistic, and non-stigmatizing care offered through the programme. However, the evaluation focused more on programme-delivery issues, and there was little information on consumer perceptions of how the programme had helped them. In a similar approach, Meehan and Robertson (2013a) carried out telephone interviews with 19 patients within 6 weeks of been discharged from the programme. While all of the patients agreed that the
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programme had helped them, details of other outcomes were not discussed. Few studies have focused on the assessment of quantitative outcomes. An evaluation of the programme funded by the Commonwealth Government (Health Management Advisers 2012) supports the positive perceptions of providers and consumers highlighted earlier. The evaluation found that hospital admissions for those enrolled in the programme decreased by 13.3% in the 12 months’ post-programme. Moreover, the average length of stay for those who required admission decreased from 37.2 to 17.7 days, which resulted in an estimated saving of $A2600 per patient. Other flow-on benefits included increased levels of employment and improved family connections. Apart from these data, no other clinical or general functioning data were reported. More recently, Lakeman and Bradbury (2013) conducted an online survey of nurses working with the MHNIP. Completed Health of the Nation Outcome Scales (HoNOS) for 64 people on admission to the programme, and again at final review, were submitted as part of the survey. Statistically-significant reductions on all HoNOS domains, except physical health, were noted. However, the researchers had no control over the patient profiles or data submitted by the nurses. The authors noted that selection bias might have contributed to the wide variation between admission and discharge scores for the client profiles that were submitted. In the present study, we compared pre-/post-clinical and general functioning data for a sample of consecutive patients who received treatment through the MHNIP.
METHOD The present study is part of a larger evaluation of the MHNIP in the Ipswich area of Queensland, Australia. This component of the evaluation focused on the outcomes for clients in the programme, and employed a single group, pre-/post-test design, where the clients were used as their own controls.
Sample All consecutive patients (n = 403), referred by GPs to seven MHN working under the MHNIP in the Ipswich area of Queensland, were invited to participate in the evaluation. Although 309 of the patients (76.6%) were enrolled in the study, follow-up data were available for a subgroup of 84 patients (27.2%). Missing data resulted from 37 patients (11.8%) being referred to psychologists or psychiatrists for ongoing treatment, and this hampered © 2014 Australian College of Mental Health Nurses Inc.
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the collection of follow-up data. Another 20 patients (6.4%) were referred to local mental health services for assessment and treatment. Eighteen other patients (6.1%) did not return for further treatment following the initial assessment, and four patients (1.3%) moved out of the catchment area. While 146 patients remained with the programme, follow-up data were available for 84 of these. The reasons for the relatively high drop-out rate vary, and tend to be either client or context dependent. Some clients dropped out, as their presenting problem had improved, others saw their GP on the final visit, and follow-up measures were not completed. Follow-up contact with some patients was by telephone, rather than in person, which resulted in measures not being completed. Finally, the MHN appeared to be more vigilant in collecting baseline data (rather than the follow-up data), which was collected during the mandatory consent procedures for client entry into the programme.
working with the GP in one of seven GP practices. Details of the evaluation were provided to each patient during the initial meeting with the MHN. Patients agreeing to participate in the evaluation were asked to sign a consent form and complete the self-report measure (DASS-21). Over the next couple of meetings, the MHN completed the clinician-rated measures (HoNOS and GAF). These same measures were completed for a second time when a patient was discharged from the programme or at 6 months’ post-entry into the programme (for those continuing with the programme). As such, there was wide variation in the follow-up period, as patients exited the programme at different time points. The follow-up period ranged from a minimum of 3 weeks to a maximum of 28 weeks (median = 15 weeks). Over this study period, patients received between one and 44 sessions (mean = 8.5, standard deviation (SD) = 18.2) with an MHN.
Measures
Data analysis
Three standardized measures were employed to assess patient well-being on entry into the programme and at follow up. Illness severity was assessed using HoNOS (Wing et al. 1996). The measure has a total of 12 scales, and these assess the severity of psychopathology and physical health over the preceding 2 weeks. Each scale is rated using a five-point Likert format (0–4), with a higher score indicating more severe problems. Emotional states were assessed using the Depression, Anxiety and Stress Scale-21 (DASS-21) (Lovibond & Lovibond 1995). The brief version of the measure contains 21 items, but scores can be doubled to correspond with the larger 42-item version of the measure. The measure has three subscales that focus on depression, anxiety, and stress. The measure is self-rated by the patient using a four-point Likert scale (0–3), with higher scores indicating more severe problems. Finally, overall functioning was assessed using the Global Assessment of Functioning (GAF) scale (Endicott et al. 1976). The measure requires the clinician to make an overall judgment about a patient’s current functioning on a continuum, from superior mental health to profound mental impairment that precludes any social or occupational competency. These ratings are made on a scale of one to 100, and unlike the other measures described earlier, lower GAF scores indicate more severe problems.
Data were cleaned and checked for errors, and analysed using the statistical package SPSS for Windows (version 18; SPSS, Chicago, IL, USA). Items in each measure were rescored in the direction outlined by the developers of the individual measures. Subscale and total scale scores were computed and used in the analysis of data from that point onwards. Descriptive statistics were used to summarize the data. Independent-samples t-tests and χ2 analyses were used to investigate whether there were any significant demographic or clinical differences in those with and without follow-up data. Paired-samples t-tests and effect sizes were used to compare changes in outcomes between baseline and follow up. The probability level was adjusted for the multiple comparisons using the Bonferroni correction to provide an adjusted probability level of 0.01 (i.e. 0.05/5 = 0.01). Cohen’s d was used to estimate the effect size of the outcome, and was calculated by dividing the mean of the difference scores (between baseline and follow up) by the pooled SD of both assessments (Cohen 1987).
Procedure The evaluation was approved by the West Moreton District Ethics Committee. All patients deemed suitable for the MHNIP were referred by their GP to the MHN © 2014 Australian College of Mental Health Nurses Inc.
RESULTS Completed pre-/post-measures were available for 84 of the 309 patients enrolled in the evaluation (27.1%). There was considerable loss of patients from the study, and it is possible that the patients with follow-up data were different in some systematic way from those lost to follow up. To assess this, we compared baseline assessment scores for those with and those without follow-up data. Those with follow-up data were significantly older
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Changes in client functioning pre-/post-intervention through MHNIP
(mean = 43.04 years) than those without follow-up data (mean = 35.65 years, t = 3.50, P = 0.001) (Table 1). While differences in total scale scores for both groups did not reach statistical significance, there was a significant difference in the social problems subscale of HoNOS. Those with follow-up data had higher mean scores (more severe problems) on the social problems subscale (t = −2.74, P = 0.006). This subscale contains four scales that assess deficits in relationships, activities of daily living, accommodation, and occupation.
Overall, the study group demonstrated significant improvement on all of the measures at follow up (Table 2). The mean total HoNOS score for the sample decreased (improved) significantly (t = 5.43, P < 0.001), from a mean of 12.01 (SD = 4.7) on entry into the programme to a mean of 9.04 (SD = 4.98) at follow up. Likewise, scores for all three DASS-21 subscales
TABLE 1: Demographic and clinical characteristics of clients with and without follow-up data Baseline for clients with follow-up data (n = 84) Mean (SD)
Variable
Baseline for clients without follow up data (n = 146) Mean (SD)
Age
43.04 (13.53)
35.65 (13.62)
Sex Male Female HoNOS total score
50 (59.52%) 34 (40.48%) 11.96 (4.58)
90 (61.65%) 56 (38.34%) 12.89 (4.73)
GAF
58.08 (11.42)
60.33 (10.57)
DASS-21 – Depression: subscale score
23.76 (12.40)
24.30 (11.48)
DASS-21 – Anxiety: subscale score
17.90 (10.48)
17.70 (11.1)
DASS-21 – Stress: subscale score
25.50 (10.54)
26.08 (10.64)
Statistics t = 3.50 P = 0.001 (χ2 = 0.04, P = 0.83).
t = 1.53 P = 0.12 t = 1.58 P = 0.11 t = 0.38 P = 0.73 t = 0.13 P = 0.89 t = 0.40 P = 0.69
DASS-21, Depression, Anxiety, Stress Scale-21; GAF, Global Assessment of Functioning; HoNOS, Health of the Nation Outcomes Scales; SD, standard deviation.
TABLE 2:
Differences between baseline and follow-up scores for patients enrolled in the Mental Health Nurse Incentive Programme
Measure HoNOS (T1) (T2) GAF (T1) (T2) DASS-21: Depression (T1) (T2) DASS-21: Anxiety (T1) (T2) DASS-21: Stress (T1) (T2)
Mean (SD)
Mean difference (SD)
t-tests (paired samples)
Effect size
12.01 (4.57) 9.04 (4.98)
−2.82 (4.31) (n = 84)
t = 5.43 P < 0.001
0.62
59.22 (10.49) 66.43 (8.92)
7.21 (14.43) (n = 83)
t = −5.46 P < 0.001
0.74
23.24 (11.46) 15.64 (12.96)
−7.60 (12.97) (n = 81)
t = 4.14 P < 0.001
0.63
16.32 (8.25) 10.92 (9.77)
−5.40 (8.98) (n = 82)
t = 3.11 P < 0.003
0.59
24.40 (9.72) 17.80 (11.75)
−6.6 (11.78) (n = 80)
t = 3.93 P < 0.001
0.61
DASS-21, Depression, Anxiety, Stress Scale-21; GAF, Global Assessment of Functioning; HoNOS, Health of the Nation Outcomes Scales; SD, standard deviation; T1, initial assessment (entry into the Mental Health Nurse Incentive Programme); T2, follow-up assessment.
© 2014 Australian College of Mental Health Nurses Inc.
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No. admissions
1000 800 600 400 200 0 2004 FIG. 1: Admissions to local acute inpatient unit over study period.
(stress, anxiety, and depression) decreased (improved) significantly between baseline and follow up. Finally, the mean GAF score increased significantly, from 59.22 to 66.43, indicating significant improvement in general functioning (mean difference = 7.21, t = −5.46, P = 0.001). The anchor for the GAF score at follow up indicates that patients had mild symptoms or some difficulty in functioning. Effect size provides a useful means of quantifying the size of the change between two assessments, and emphasizes the clinical usefulness (rather than the statistical significance) of an intervention. Cohen (1987) suggests that effect sizes of 0.20 are small and indicate that a given intervention has negligible clinical importance; values of 0.50 indicate that the programme has moderate clinical importance, and values of 0.80 or more are large and indicate interventions have high clinical importance. In the present study, effect sizes ranged from 0.59 to 0.74 (Table 2). The interventions provided through the MHNIP appeared to have the least impact on anxiety (d = 0.59) and the greatest impact on general functioning (d = 0.74), as measured by the GAF scale.
Admission to acute care since the introduction of the MHNIP Data relating to the number of patients admitted to the Acute Care Unit at Ipswich Hospital between 2004 and 2012 are displayed in Figure 1. These data indicate that admissions to the unit have remained relatively stable since 2008 (when the programme commenced in the Ipswich area). The average number of admissions to the acute unit in the 4 years prior to 2008 was 834 (SD = 48.0), and for the 4 years following 2008, it was 781 (SD = 36.6, t = 1.74, P = 0.13).
DISCUSSION The rapid implementation and expansion of the MHNIP in Australia has hampered attempts to adequately evalu© 2014 Australian College of Mental Health Nurses Inc.
2005
2006
2007
2008
2009
2010
2011
2012
Year
ate its impact (Olasoji & Maude 2010). While the present study adds to our understanding of the programme, it has a number of limitations. The nurses involved were aware of the evaluation aims, and had a vested interest in demonstrating that the programme was effective. They could have unintentionally introduced bias when completing the observer-rated measures (HoNOS, GAF) at follow up, by perceiving their patients in a more positive light (Lakeman & Bradbury 2013). Nonetheless, the DASS-21 measure was completed directly by the patients, and the findings from this also pointed to significant improvements. It is also possible that patients could have improved over time due to the natural course of the illness; they might have improved, even if they did not receive the intervention. In the absence of a control group, some degree of caution is required when attributing the significant outcomes identified to the programme. Like most naturalistic studies, there was considerable loss of clients from the study. While attempts were made to recruit all consecutive patients, only 309 of a possible sample of 403 patients were enrolled in the study. It is clear that some of the MHN involved were more successful at recruiting clients for the evaluation. While one of the nurses enrolled 91% of their clients, another could only recruit 22% of their clients. Notwithstanding this, we secured paired data for 21% of clients, which compares favourably to the 15% of clients with paired data in the national evaluation of the Access to Allied Psychological Services (ATAPS) programme (Pirkis et al. 2010). Future evaluations of the MHNIP should consider recruitment issues, and work more closely with the nurses involved to improve recruitment. Systematic bias might have been introduced through the loss of patients with more severe problems from the programme. However, examination of assessment data at baseline identified few differences in those with/without follow-up data. Nonetheless, those with follow-up data (i.e. those who remained in the programme) were
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significantly older and had more severe problems during initial assessment on the ‘social’ subscale of HoNOS. This subscale assesses four aspects of functioning (relationships, activities of daily living, accommodation and occupation). Lakeman and Bradbury (2013, p. 334) noted that the MHNIP appears ‘to facilitate meeting psychosocial and relational needs’, and as such, patients with social problems might have engaged more fully with the programme. Overall, the MHNIP appears to be targeting patients with severe mental conditions. The mean total HoNOS score for patients in our sample was 12.01 (SD = 4.6) on entry into the programme, which is compared to a mean score of 15.4 (SD = 6.7) for those admitted to hospital (Meehan & Robertson 2013b). The mean of 12.01 is significantly lower than the mean of 21.47 (SD = 7.8) reported by Lakeman and Bradbury (2013) in their national survey. This variation in admission scores points to large clinical differences in the clients treated through the programme. While the completion of HoNOS is mandated for all clients supported through the MHNIP, there is no system in place at the national level to capture and report on these data. In the absence of national summary data, it is difficult to draw conclusions about illness severity in those treated at the different sites. Indeed, Meehan and Robertson (2013b) have recommended a broader range of measures to assess the severity of high-prevalence illnesses (e.g. depression, anxiety), as this would enable direct comparison of outcomes with other similar programmes, such as ATAPS. The present study found highly-significant improvements on all of the domains assessed. The total HoNOS score decreased (improved) significantly, from a mean of 12.01 on entry into the programme to a mean of 9.04 at the point of discharge from the programme. This score is similar to the discharge score of 9.61 reported by Lakeman and Bradbury (2013) in their national sample. This seems to suggest that, despite the disability level on entry into the programme, clients either leave or are discharged from the programme when their HoNOS score decreases to a range of between nine and 10. Participation in the programme also resulted in a significant improvements in emotional states. There were statistically-significant improvements in levels of depression, anxiety, and stress between baseline and follow up. While the change scores were statistically significant, they were also clinically significant. Effect sizes ranged from 0.59 to 0.74. The findings suggest that the MHNIP is making a positive contribution, with a medium-to-large
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impact on the mental health and general functioning of individuals enrolled in the programme. One goal of the MHNIP is to reduce the need for hospital admission for people with severe mental conditions (Australian Government Department of Health and Aging 2010). A recent evaluation of the MHNIP across Australia showed that hospital admissions for mental illnesses decreased by 13.3% in the 12 months following involvement with the programme (Health Management Advisers 2012). As it proved too difficult in the present study to track patients once they left the programme, we examined admission data for the local inpatient unit. While the average number of admissions to the inpatient unit decreased in the 4 years since the programme commenced, the decrease was not statistically significant. The finding supports earlier UK research, which found that the introduction of a mental health team at a GP clinic did not decrease utilization of inpatient beds or emergency department contacts (Jackson et al. 1993). It is clear that admission to acute inpatient care can be influenced by a number of factors, including the availability of beds. As such, it is possible that the programme did reduce the need for hospital admission in MHNIP patients, but these beds were allocated to other people. It is recommended that future evaluations of the programme establish methods for gathering data on the number of admissions and days spent in hospital pre-/post-engagement with the MHNIP. The findings presented here focus on clinical functioning, and not on functioning more broadly. It is clear from related studies (Health Management Advisers 2012; Meehan & Robertson 2013a) that other indices of functioning, such as employment and quality of life, are also likely to improve due to the MHNIP. Future evaluations should, in addition to clinical functioning, examine these broader (‘non-clinical’) aspects of functioning. Finally, despite the positive outcomes for clients in this and previously-published independent evaluations, the fate of the MHNIP remains unclear. The Australian Government has maintained funding for the 2014–2015 year at 2013–2014 levels, and there is no guarantee that the programme will continue beyond June 2015. It has called for a review of all existing mental health programmes to identify gaps in service provision and ensure that mental health services are not being duplicated (Australian Government Medicare Australia 2009). While this review will focus on process issues, it must also consider the positive evaluation findings and feedback from consumers and providers. © 2014 Australian College of Mental Health Nurses Inc.
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CONCLUSIONS The MHNIP represents another step in the long road towards mainstreaming mental health services into the general health system. The findings from this evaluation shed light on the outcomes that can be expected from the programme. It is likely that the programme is achieving a positive effect, in the medium-to-large range, for patients with mental illnesses. Should the programme continue to be funded, research is required to determine if the positive findings identified in this evaluation can be applied more broadly. It is recommended that a minimum dataset (focusing on clinical, non-clinical, cost, and demographic data) be developed and implemented to facilitate ongoing evaluation of the programme.
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81 outcomes. International Journal of Mental Health Nursing, 19, 331–339. Health Management Advisers (2012). Evaluation of the Mental Health Nurse Incentive Program. Department of Health and Aging. [Cited 8 March 2013]. Available from: URL: http:// www.health.gov.au/internet/main/publishing.nsf/Content/ work-pr-mhnip#eva Jackson, G., Gater, R., Goldberg, D., Tantam, D., Loftus, L. & Taylor, H. (1993). A new community mental health team based in primary care. A description of the service and its effects in the first year. British Journal of Psychiatry, 162, 375–384. Lakeman, R. (2013). Mental health nurses in primary care: Qualitative outcomes of the Mental Health Nurse Incentive Program. International Journal of Mental Health Nursing, 22, 391–398. Lakeman, R. & Bradbury, J. (2013). Mental health nurses in primary care: Quantitative outcomes of the Mental Health Nurse Incentive Program. Journal of Psychiatric and Mental Health Nursing, 21, 327–335. Lovibond, S. & Lovibond, P. (1995). Manual for the Depression Anxiety Stress Scales, 2nd edn. Sydney, Australia: Psychological Foundation of Australia. Meehan, T. & Robertson, S. (2013a). The Mental Health Nurse Incentive Program: Reactions of general practitioners and their patients. Australian Health Review, 37, 337–340. Meehan, T. & Robertson, S. (2013b). Clinical profile of people referred to mental health nurses under the Mental Health Nurse Incentive Program. International Journal of Mental Health Nursing, 22, 384–390. Olasoji, M. & Maude, P. (2010). The advent of mental health nurses in Australian general practice. Contemporary Nurse, 31, 106–117. Pirkis, J., Burgess, P., Kohm, F., Morley, B., Blashki, G. & Naccarella, L. (2006). Models of psychological service provision under Australia’s Better Outcomes in Mental Health Care (BoIMHC) program. Australian Health Review, 30, 277–285. Pirkis, J., Bassilios, B., Fletcher, J. et al. (2010). Evaluating the Access to Allied Psychological Services (ATAPS) Component of the Better Outcomes in Mental Health Care (BoIMHC) Program. Melbourne: Centre for Mental Health Policy, Programs and Economics, University of Melbourne. Senate Community Affairs Committee (2012). Health and Aging Portfolio. Answers to Estimates Questions on Notice (Question E12-143). Canberra: Senate Affairs Committee. Wing, J., Beevor, A., Curtis, R., Park, S., Hadden, S. & Burns, A. (1996). Health of the Nation Outcome Scales (HoNOS). Report on research and development. British Journal of Psychiatry, 172, 11–18.
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