Community Ment Health J DOI 10.1007/s10597-013-9684-5
ORIGINAL PAPER
Use of Structured Clinical Documentation to Identify Patients’ Parental Concerns and Their Childrens’ Wellbeing Georgios Liangas • Adrian Falkov
Received: 12 April 2012 / Accepted: 3 December 2013 Springer Science+Business Media New York 2014
Abstract Children of parents with mental illness are at high risk of adverse health and functional outcomes, but little is known about how the community mental health staff identify and document these. This file audit examines parents’ case managers’ recording of children’s needs and safety, on relevant components of New South Wales’ Mental Health Structured Clinical Documentation. The audit identified 280 parental files. Study findings indicate that parenting issues form an important load of work on community mental health teams, highlighting the need for systematic identification of parental status in mental health patients. Keywords Family Community Mental Health Services Parents Child Documentation
Introduction Children of parents experiencing mental illness are now widely acknowledged as being at very high risk for a range of adverse mental health (MH), physical health, social, educational and relationship outcomes. These children are at increased likelihood of developing their parent’s illness, developing other emotional problems, behavioural problems, social, substance use disorders, interpersonal difficulties and attachment difficulties (Beardslee et al. 1998; Oates 1997; Niemi et al. 2005). These risks are evident G. Liangas 1B Grose St, North Parramatta, NSW 2151, Australia A. Falkov (&) Redbank House, Westmead Hospital, Western Sydney Local Health District, PO Box 533, Wentworthville, NSW 2145, Australia e-mail: [email protected]
across the lifespan and across generations (Beardslee et al. 1998; Oates 1997; Niemi et al. 2005; DelBello and Geller 2001; Falkov 2012). As a group they provide an important opportunity to better understand causal influences in psychopathology and the interplay of risk and protective factors in individuals and families. This is so particularly given that not all children will be adversely affected and some show remarkable capacity to survive and thrive despite their adverse life experiences (Masten 2001). Despite research into the effects of mental illness on patients’ children, much less has been studied about how psychiatric services support their patients who are parents in their parenting role (Korhonen et al. 2010). The available evidence shows ongoing variability in the extent to which parental status is routinely identified in MH services, and in the assessment and intervention of family needs (Nicholson and Biebel 2002). Most parents who are mental health consumers do not seek support from their mental health clinicians in their parenting role. Some reasons for this include the fear of being judged as poor or inadequate parents, and fear of losing custody or access to their children (Diaz-Caneja and Johnson 2004). In turn, various barriers have been described for adult mental health clinicians related to difficulties in identifying the parents within their cohort, and incorporating parenting and children’s needs into assessment, support and intervention (Fudge et al. 2004). Locally, the New South Wales (NSW) Government in its policy directive on children of parents with mental illness (COPMI) has highlighted the need for prevention of mental disorders in children, addressing stigma and equity of access to services, and providing integrated services for patients and families (NSW Health 2010). Identification of parents with mental illness is a key part of this policy, and
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the use of specific parts of NSW’s Structured Clinical Documentation (SCD) forms is considered an important tool in such identification. The introduction of an SCD approach is one general approach to raising standards across MH services in NSW (NSW Health 2006). SCD has been shown to improve quality of clinical documentation of key issues such as risk of harm to self (NSW Health 2004) as well as improving clinical confidence, reducing training requirements and a familiar, standardised format leading to improved clinical decision making (Bar-on and Zanga 1996). The system of SCD designed and implemented in NSW MH is the Mental Health Outcomes and Assessment Tool (MHOAT). This was reviewed and the revised SCD was implemented in all Area Health Services (AHS) in 2008 (NSW Health 2008a). Notable in the revision was the modular approach consisting of mandatory and non mandatory modules. An example of the former is the Mental Health Assessment (MHA) module and of the latter the Family Focused Assessment (see ‘‘Appendix’’) (NSW Health 2008b). The FFA is an example of a specific initiative to support clinicians in identifying and supporting COPMI families. It is a two-page document which guides the recording of information covering a number of key domains relating to the potential effects of the parent’s psychiatric symptoms on parenting, indicators of child functioning and potential hazards to child safety and wellbeing, and appraisal of protective and vulnerability factors. Its purpose is to aid the mental health clinician in considering the effects of the patient’s condition on parenting, and vice versa. A second specific initiative to promote family sensitive practice in MH services was the provision of training on the impact of parental mental illness on children using the Crossing Bridges NSW (CBNSW) materials. CBNSW is a locally adapted version of the original British Crossing Bridges training program (Falkov 1998).
Here we report findings of a case note audit examining MH clinicians’ use of relevant components of (MHOAT) SCD regarding identification, assessment and intervention for COPMI families known to selective Community Mental Health Teams (CMHTs) in SWAHS. The timing of the audit enabled comparison of clinical documentation usage and quality before and after case managers received CBNSW training.
Methods At the time of study, public health services in NSW, including Mental Health, consisted of 8 large geographic regions (AHS) and two state-wide entities. In rolling out the CBNSW training, a defined number of one-day training sessions was offered to each AHS on a ‘1st come 1st served’ basis. Funding was for a series of one-day training workshops for each AHS, one of which included the Sydney West Area Health Service (SWAHS). Following NSW Health Service restructure, SWAHS has become the Western Sydney Local Health District (LHD) and the Nepean Blue Mountains LHD. According to the 2006 Census, SWAHS had a population of 1,060,673 (NSW 7,107,512) Sydney West Area Health Service (2011). While SWAHS had pockets of affluence, overall it serves moderate to severe social disadvantage (see Table 1) (Australian Bureau of Statistics 2006). Community MH services were organised across 15 Community Mental Health Teams (CMHTs), based around the boundaries of Local Government Areas. In SWAHS, CBNSW took place on five occasions during August-November 2009. The training commenced 11 months after revised SCD was implemented and included a section on use of the FFA. Adequate staffing levels in Mental Health Services are determined in NSW by the use of the Mental Health— Clinical Care and Prevention Service Planning Model
Table 1 Number of audited files, staffing levels and index of social disadvantage for each CMHT audited CMHT
No. of patients
Staffing levels (% of MH-CCPa) Jan 2009
Staffing levels (% of MH-CCPa) May 2010
Index of social disadvantage decileb
Youth team (18–25 years) A
8
N/A
N/A
5
Youth team (18–25 years) B
2
N/A
N/A
1&5
Case management team A
38
34
17
4
Case management team B
28
43
37
2
Case management team C
14
43
45
9
Case management and acute team A
142
35
26
5
Case management and acute team B
48
26
19
1
N/A = Not available; team leaders were not able to provide this data in the time provided a
Number of staff as a percentage of ideal staffing levels proportional to the population, according to the Mental Health Clinical Care and Prevention (MH-CCP) model (NSW Health 2009)
b
1 = Top 10 % of social disadvantage; 10 = Bottom 10 % of social disadvantage (Australian Bureau of Statistics 2006)
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Files on SCI
Files located
File where consumer was identified as a parent
Time 1
Time 2
N/A
676
98
70
112
182 (33% of files located)
Total number of files audited
PM identification
549 (81%)
N/A
In Time 1 of the audit, file identification varied according the team leader’s discretion.
70 files were identified in T1 and T2. In these cases, the files were not re-audited.
280
117 (61%)
58 (65%)
Total PM identified
175 (63%)
Intervention provided
96 (34%)
P=0.53 (χ2)
Fig. 1 Number of patient files at different stages of the audit
(MH-CCP) (NSW Health 2009). In collaboration with CMHT team leaders this model was used to determine actual staffing levels of the audited CMHTs at the time of the audit, as a percentage of ideal staffing levels. Sample Recruitment Resources prevented an area-wide audit of all 15 CMHTs in SWAHS. Teams were invited to participate by phone and email to the team leaders of all adult (18–65 years) CMHTs in SWAHS explaining the purpose of the audit. The first eight CMHTs whose team leaders responded were
included, with one exclusion due to the absence of any staff participating in CBNSW training. A two-phase recruitment was undertaken at each of two time points (T1 and T2—see Fig. 1). Phase 1 consisted of obtaining a list of all referred and accepted patient/client files (of adults aged 18–65) at each of the two time points and screening for parental status. At T1, files with a completed episode of care between 1/1/2009 and 1/2/2010 were identified by each team leader. At T2 the recruitment procedure was revised utilising central (electronic) identification through the service contact information (SCI) electronic database, for all adult patients with completed
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episodes of care between 1/8/2009 and 23/5/2010. At both time points files were then obtained from records department and each file was examined to determine parental status and presence of dependent children (\18 years). At each time point, phase 2 involved detailed case notes review of patient-parents (obtained from phase 1 screening). A proforma was used to gather more detailed information including family demographics; details about dependent children (number of children, ages, gender and whether they were living with the patient at the time of assessment); information relating to the presenting problem; safety and wellbeing of children; the presence of family supports; parenting difficulties and whether the case manager had inquired but not identified parenting difficulties or children’s needs and use of the FFA. The proforma was based on family-relevant categories and sections from the Modules comprising SCD: the Assessment, Triage, Review, Care Plan Risk Assessment & FFA modules. Patient files were screened carefully across the two recruitment phases to avoid duplication. There was no practical way of checking whether patients were partners of other audited patients. Each case manager was identified by locating their name on the discharge summary or (if no discharge summary), MH worker with most casenote entries. Files were then categorised according to whether the case manager had undergone CBNSW training, and whether the episode of care occurred before, during or after training. A case was deemed to be open during training if the file was open at any time between the dates that all case managers of the patient’s CMHT received training. The audit was approved as a Quality Assurance audit by the Sydney West Area Health Service Human Research Ethics Committee.
Results Identification of Parents A total of 280 files were audited, 175 of which had a parenting issue identified. For the T2 period, 33 % of patients were parents. A variable response from different teams regarding referral number, case ascertainment and casenote location at T1 means that the T1 parent prevalence figure was not robust. The T2 figure of 33 % (182/ 548) is based on a more systematic sample of referrals, and better casenote retrieval. Of the 280 parents, 167 (60 %) had an episode of care of less than 1 month, 71 (25 %) had an episode of care lasting 1–6 months, and 42 (15 %) had an episode of care lasting more than 6 months.
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Quantitative Use of SCD Examining the completion rates of SCD forms (including partial completion), 126 files (45 %) had a MHA form completed during the current episode of care, and 191 (68 %) had either a MHA form or A1 (the original version of the MHA form prior to redesign) completed at any time. 203 files (73 %) had a Triage form completed. Nine files (3 %) had a Family Focused Assessment form. 154 files (55 %) had at least one other form completed that was relevant to the audit (Risk Assessment, Domestic Violence Screen, Review, Care Plan, Consumer Wellness Plan). Demographic Details The age range of parents was 18–59 years (mean of 36.3), 186 of whom were female (66 %). 40 % were married or cohabiting, 35 % single, separated, divorced or widowed and in a quarter of cases marital status was not provided. At T2, 49 % of all patients were male, but only 37 % of patients identified as parents were male. There were 557 children documented in 277 of the 280 files (99 %), with equal gender distribution (212 girls) and gender unrecorded for 25 %. There was a relatively even age distribution, with age undocumented in 44 children (8 %). Residential status of children was recorded for 216 parents (77 %), over half of whom (148 parents) had their children living with them. 52 parents (19 %) did not have children living with them. In 16 files (6 %) residential status was unclear. Documentation of Clinical Need in Families and Service Responses At least one parenting issue was documented in 175 case notes (63 %). The five most common parenting issues were: (1) the parent expressing significant difficulties coping with the parental role (41 %), (2) parents relied on their children for support (29 %), (3) the patient’s illness or family factors impacted negatively on the child’s safety and welfare (27 %), (4) documentation of parenting supports (family and services) (25 %), and (5) aspects of children’s welfare have been considered and appear to be adequate (23 %). Note that often more than one issue was identified in each file. Parenting issues were mentioned as part of the presenting problem in 92 patients (53 % of files with a parenting issue). The 5 most common parenting issues as part of the presenting problem were: (1) Significant difficulties with the parental role (48 %), (2) the patient’s illness or family factors impacted negatively on the child’s safety and welfare (27 %), (3) custody disputes and separation problems were contributing to parental psychopathology (27 %), (4) parental reliance on children for support (21 %), and (5) children with disruptive, oppositional or
Community Ment Health J
aggressive behaviour were contributing to parental stress (18 %). Interventions relating to parenting issues were documented in 96 files (55 % of files with a parenting issue). The 5 most common interventions were: (1) referral to or liaison with the child protection agency (44 %), (2) referral to early childhood, perinatal, disability, parenting or family support service(s), (3) management of parenting by Mental Health case manager (25 %), (4) recommendation for private psychologist for parent (22 %), and (5) liaison with or referral to patient’s GP or private psychiatrist (14 %). Clinicians appeared more likely to identify and record a parenting issue: • •
•
In mothers compared to fathers (69 vs 49 %, p = 0.001). If children were living with the identified ill parent compared to non-custodial patient-parent (69 vs 38 %; p \ 0.001). In married/defacto parents and separated/divorced parents compared to single parents (68 and 64 vs 33 %, p = 0.001).
The labour-intensive process of ascertaining parental status emphasises the need for more systematic and accessible administrative procedures for documentation of patients who are parents. This finding has implications for all services involved with adults experiencing mental health problems. There is a need for mechanisms to ensure mandatory identification of adult patients who are parents at the point of first contact with services and to ensure that this information is incorporated into clinical work at the outset (Fletcher et al. 2012). Demographics of Children Children of all ages were recorded in this audit, highlighting the need for a developmental approach to cater for the spectrum of presentation. There was a much higher proportion of missing data for children’s gender (25 %) than children’s age (8 %). The SCD sections from which this data was extracted asked specifically for age and not gender, indicating the usefulness as well as limitations of SCD in promoting a comprehensive approach to assessing need. Clinical Implications
The Influence of Training on Case Manager Documentation of Family Needs Eighty-four of approximately 1,100 (McMillan A, personal communication, 2011 May 19) Mental Health Staff from inpatient and community settings completed CBNSW training during August–November 2009. Of these, 25 were case managers of patients audited in the study, accounting for 189 patients (7.6 patients per case manager). A further 18 case managers (not completing training) case managed patients audited in the study, accounting for 91 patients (5.1 patients per case manager). This difference of case manager load was not significant (v2 20.1, p = 0.11). There were no significant differences in case note identification of parenting needs between case managers who received and those who did not receive CBNSW training. There were also no differences in CM recording behaviour prior to and subsequent to training.
There were notable weaknesses in uptake and utilisation of even mandatory modules such as the MHA (completion rate of 45 %). Regarding a specific family (COPMI) focus only 3 % of files had a completed FFA, with no improvement following targeted training. This was despite the fact that CBNSW had been modified to facilitate use of the FFA. Furthermore, even when the forms were completed, there was a high rate of missing data (e.g. child demographics). As the vignettes show, the files that included an FFA had greater potential for documenting parenting issues. It was also difficult to determine whether the gaps in documentation were related to gaps in history taking or gaps in documenting elicited information. Progress notes were audited in a very limited way, and it was therefore also difficult to determine whether the limitations in documentation were general or related to SCD aversion. This has implications for the design and delivery of training.
Discussion
Parenting Needs of Adults Known to CMHTs
Screening and Identification of Patients Who are Parents
Amongst adults known to CMHTs, parenting-related difficulties constituted a considerable proportion of presentations to MH services. Despite being a minimum estimate, approximately two-thirds of files made some reference to parenting issues and child wellbeing and safety. In half these cases, parenting matters contributed directly to the presentation to MH services, reinforcing evidence for links between parenting, mental health and children’s wellbeing
One-third of patients known to CMHTs were parents, highlighting that they constitute an important proportion of the caseloads of staff in community AMH services. This also represents a minimum estimate and is consistent with data reported elsewhere (Fudge et al. 2004).
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Community Ment Health J Table 2 Examples of clinical need in families & interventions documented in files The 5 most common parenting issues identified in the patient file
Number of files (%)
Parent expressing significant difficulties coping with parental role
71 (41)
Children relied on by parent for support
50 (29)
Child safety and welfare concerns resulting from parent’s illness or family factors
47 (27)
Documentation of parenting supports (family and services)
45 (25)
Aspects of children’s welfare and safety have been considered and appear to be adequate a
40 (23)
The 5 most common parenting issues as part of presenting problem (92/175)
Number of files (%)
Significant difficulties coping with the parental role
44 (48)
Child safety and welfare concerns resulting from parent’s illness or family factors
25 (27)
Custody disputes and separation problems contributing to parental psychopathology
25 (27)
Parental reliance on children for support
19 (21)
Children with disruptive, oppositional, or aggressive behaviour contributing to parental stress
17 (18)
The 5 most common interventions (96/280)
Number of files (%)
Referral to or liaison with child protection agency
42 (44)
Referral to early childhood, perinatal, disability, parenting or family support service(s)
42 (44)
Management of parenting by MH case manager
24 (25)
Recommendation for private psychologist for parent
21 (22)
Liaison with or referral to patient’s GP or private psychiatrist
13 (14)
a
[1 problem documented in casenotes for a number of parents
and safety (Fudge et al. 2004). The audit also shows that when identification and assessment of parenting matters is undertaken and recorded, then intervention does occur. The most common interventions provided by case managers (Table 2) gives some insight into the priorities of case managers who do identify PMs. The most common intervention is liaison with child protection services. Health staff in NSW are ‘mandatory reporters’ of children at risk of harm; therefore the frequency of this intervention may be a reflection that urgent child safety matters do take priority. The next most frequently documented interventions appear to be parentcentred, with less child-centred interventions such as referral to or liaison with a paediatrician, a child and adolescent mental health team or a school counsellor. Considerable potential therefore exists for more proactive efforts in non-mandatory, child-focused parenting issues. Given that the index person is the adult (not the child), MH services are well placed to intervene earlier and more quickly with children if there is systematic identification and screening in place. This is important because substantial early intervention opportunities exist within Adult MH services if children are identified and provided with support according to their level of need (Falkov 2012). Not all children require specialist intervention and there are evidence based interventions available for this cohort of families, especially for facilitating improved communication and explanations
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between parents and children (Solantus et al. 2009; Beardslee et al. 2009). In turn such an approach can reduce the burden on parents and facilitate their own recovery. The audit also highlighted under-identification of parenting issues in males (fathers), parents whose children do not live with them, and single parents. This supports the need for a focus on fathers generally as well as addressing issues of loss for non-custodial parents, especially fathers, and the nature of support required for single parents (Pethick 2011). Further research is needed to examine the types and nature of supports and intervention required for these particular family subgroups (Falkov 2012). Training Needs of MH Clinicians in CMHTs The audit design was not able to adequately test the efficacy of CBNSW training given the low number of participants. A further complication to training quality impact was that many files had no clear documentation of individual case manager. In many files multiple people were involved in a parent’s care, and the discharge person was often a different CM to the one who did most of the case managing. This made it difficult to differentiate the quality of a single case manager‘s documentation and that case manager’s capacity to incorporate CBNSW training into clinical work. Being a naturalistic study that precluded blinding and randomisation
Community Ment Health J
may also have led to intervention effects on case managers who did not undergo training. Furthermore, it is also likely that a time limited, non recurrent, stand-alone, one-day training program with limited staff coverage was insufficient to demonstrably influence family focused practice in relation to identification and documentation practices. This has important implications for development and delivery of sustainable education & training programs and the need for an overarching training strategy (Maybery and Reupert 2006). Methodological Limitations Whilst the selected CMHTs were not grossly dissimilar to those not included in the audit, the non-random selection of only half the 15 CMHTs in SWAHS indicates the need for caution in generalising the findings. Although there are pockets of affluence in SWAHS, all teams generally serve areas of considerable psychosocial deprivation and are subject to similar workforce and resource pressures with similar training implications (refer to Table 1). A more detailed within-group analysis of staffing and case load in different CMHTs and associated quality of documentation was not within the scope of this paper. No data was gathered for non-included teams. A further selection bias favoured shorter episodes of care, thus focusing more on emergency-type presentations and less on patients that require long-term treatment. Further analysis is required as to whether identification of parenting issues differs for crisis presentations compared to longer-term case-managed patients, and whether the parenting issues and child safety and welfare concerns are similar in these two groups. The first audit round was inconsistent in the way completed episodes of care were identified, and the proportion of case notes that could not be located was high. Hence the robustness of the T1 prevalence figure is uncertain. Looking Ahead The NSW COPMI Framework was published in 2010 (NSW Health 2010) and a local (SWAHS) implementation plan was developed and endorsed in 2011. The audit data helped to shape the local Implementation Plan by quantifying the number of families at risk and by showing that when staff identified adults they were able to specify parenting issues in a substantial proportion of families. In turn this helped to demonstrate the relevance of a family focus within the adult MH service and facilitated endorsement of a set of minimum (family focussed) standards across the service. For example, monitoring of the number of FFAs undertaken each month and setting a target to identify 100 % of referred adults who are parents (by mid 2015).
Modifications have also been undertaken with the electronic patient/consumer activity recording to ensure greater accuracy in capturing the number of adults who are parents, details about their children and the family focussed interventions that are undertaken. An implementation committee with high level representation across the MH service now meets on a regular basis to monitor the implementation Plan and assist with addressing ongoing barriers to family focussed practice. Finally, it is worth noting that the changes that have been undertaken to date have occurred within existing teams without additional resources, demonstrating at least to some degree, more appropriate use of existing resources and, hopefully strengthening the argument for investment of new resources. Acknowledgments The authors are grateful for assistance provided by: Donna Gillies (Senior Research Officer), Robyn Bowcock (Quality Systems Manager), and the COPMI coordinators of Western Sydney Local Health Network (prior Sydney West Area Health Service). Neda Dusevic (Former Project Manager MHOAT, InforMH). Participating Service mangers, Team Leaders and Community Mental Health Teams. Financial assistance was provided in the form of a Fellowship for Advanced Training in Child and Adolescent Psychiatry, funded by NSW Health and administered by the NSW Institute of Psychiatry.
Appendix The FFA is an example of a specific initiative to support clinicians in identifying and supporting Copmi families. It is a two page document which guides the recording of information covering a number of key domains. Page 1 focuses on current identified parent/carer symptoms and behaviours associated with current mental state, insight and judgement, co morbid conditions, and self reported concerns. Each item has a number of prompts to facilitate inquiry and responses can be recorded as present, absent or not known. There a section for the child’s current functioning regarding physical and psychosocial health and development as well as a section for self reported concerns. The final section provides for recording of concerns by others regarding the child’s wellbeing and safety. This includes concerns expressed by relatives, friends or neighbours as well as concerns expressed by staff in other services including teachers. Page 2 provides a summary page for recording current and lifetime risk and protective factors relating to the child, parent/carer and family. It covers a number of key domains in which to consider risk as well as protective factors. These include parent/carer mental health history; drug and alcohol history; family medical history; family of origin (childhood) experiences, parental functioning and social support as well as children’s developmental and personal history, impairments and supports.
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Importantly, it provides an overview section to record a summary of impairment relating to parenting, capacity to undertake daily activities and adverse impacts on the child. The intention is for key information to be collated, analysed and recorded as part of the care planning process. Specific actions related to parental support, child safety and wellbeing can be documented. Clinicians therefore have a structured record of information to inform care planning and decision making which takes account of the interplay of risk and protective factors in individuals and the various family interactions. The FFA is available, along with other MHOAT forms, at http://www.health.nsw.gov.au/policies/ib/2008/ pdf/IB2008_047.pdf.
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NSW Health (2004). NSW Government response to tracking tragedy 2004 (Internet). 2005 Dec 31 [cited 2011 Nov 23]. http://www. health.nsw.gov.au/pubs/2005/track__trag_06.html. NSW Health (2006). Mental Health Outcomes and Assessment Tools (MH-OAT) Data Collection Reporting Requirement 1 July 2006 (Internet). 2006 Jun 28 [cited 2011 Nov 23]. www.health.nsw. gov.au/policies/pd/2006/pdf/PD2006_041.pdf. NSW Health (2008a). Mental Health Clinical Documentation— Redesigned [Internet]. 2008 Sep 15 [cited 2011 Nov 23]. http:// www.health.nsw.gov.au/policies/gl/2008/pdf/GL2008_016.pdf. NSW Health (2008b). Redesigned Mental Health Clinical Documentation: Notification of availability [Internet]. 2008 Sep 15 [cited 2011 Nov 23]. http://www.health.nsw.gov.au/policies/ib/2008/ IB2008_047.html. NSW Health (2009). Mental Health Clinical Care and Prevention Model—User Guide (Internet). 2009 Sep 10 [cited 2011 Nov 23]. http://www.health.nsw.gov.au/resources/mhdao/MH_CCP_User_ Guide_pdf.asp. NSW Health (2010). Children of Parents with a Mental Illness (COPMI) Framework for Mental Health Services (Internet). 2010 Jun 17 [cited 2011 Nov 23]. http://www.health.nsw.gov.au/ policies/pd/2010/PD2010_037.html. Korhonen, T., Vehvilainen-Julkunen, K., & Pietila, A.-M. (2010). Do nurses support the patient in his or her role as a parent in adult psychiatry? A survey of mental health nurses in Finland. Archives of Psychiatric Nursing, 24(3), 155–167. Masten, A. S. (2001). Ordinary magic. Resilience processes in development. American Psychologist, 56(3), 227–238. Maybery, D., & Reupert, A. (2006). Workforce capacity to respond to children whose parents have a mental illness. Australian and New Zealand Journal of Psychiatry, 40, 657–664. Nicholson, J., & Biebel, K. (2002). Commentary on ‘‘Community mental health care for women with severe mental illness who are parents’’—The tragedy of missed opportunities: What providers can do. Community Mental Health Journal, 38(2), 167–172. Niemi, L. T., Suvisaari, J. M., Haukka, J. K., & Lonnqvist, J. K. (2005). Childhood predictors of future psychiatric morbidity in offspring of mothers with psychotic disorder: Results from the Helsinki High-Risk Study. British Journal of Psychiatry, 186, 108–114. Oates, M. (1997). Patients as parents: The risk to children. British Journal of Psychiatry—Supplement, 32, 22–27. Pethick, L. (2011). Focus on fathering: Book review (Internet). Sydney: Australian Infant, Child Adolescent and Family Mental Health Association Ltd. AICAFMHA; [cited 2011 Sep 2]. http:// www.aicafmha.net.au/resources/reviews/fathering.html. Solantus, T., Paavonen, E. J., Toikka, S., & Punama¨ki, R. L. (2009). Preventive interventions in families with parental depression: Children’s psychosocial symptoms and prosocial behaviour. European Child and Adolescent Psychiatry, 19(12), 883–892. Sydney West Area Health Service (2011). Social and health atlas (Internet). [cited 2011 Apr 11]. http://www.swahs.health.nsw. gov.au/atlas/index.htm.
ORIGINAL PAPER
Use of Structured Clinical Documentation to Identify Patients’ Parental Concerns and Their Childrens’ Wellbeing Georgios Liangas • Adrian Falkov
Received: 12 April 2012 / Accepted: 3 December 2013 Springer Science+Business Media New York 2014
Abstract Children of parents with mental illness are at high risk of adverse health and functional outcomes, but little is known about how the community mental health staff identify and document these. This file audit examines parents’ case managers’ recording of children’s needs and safety, on relevant components of New South Wales’ Mental Health Structured Clinical Documentation. The audit identified 280 parental files. Study findings indicate that parenting issues form an important load of work on community mental health teams, highlighting the need for systematic identification of parental status in mental health patients. Keywords Family Community Mental Health Services Parents Child Documentation
Introduction Children of parents experiencing mental illness are now widely acknowledged as being at very high risk for a range of adverse mental health (MH), physical health, social, educational and relationship outcomes. These children are at increased likelihood of developing their parent’s illness, developing other emotional problems, behavioural problems, social, substance use disorders, interpersonal difficulties and attachment difficulties (Beardslee et al. 1998; Oates 1997; Niemi et al. 2005). These risks are evident G. Liangas 1B Grose St, North Parramatta, NSW 2151, Australia A. Falkov (&) Redbank House, Westmead Hospital, Western Sydney Local Health District, PO Box 533, Wentworthville, NSW 2145, Australia e-mail: [email protected]
across the lifespan and across generations (Beardslee et al. 1998; Oates 1997; Niemi et al. 2005; DelBello and Geller 2001; Falkov 2012). As a group they provide an important opportunity to better understand causal influences in psychopathology and the interplay of risk and protective factors in individuals and families. This is so particularly given that not all children will be adversely affected and some show remarkable capacity to survive and thrive despite their adverse life experiences (Masten 2001). Despite research into the effects of mental illness on patients’ children, much less has been studied about how psychiatric services support their patients who are parents in their parenting role (Korhonen et al. 2010). The available evidence shows ongoing variability in the extent to which parental status is routinely identified in MH services, and in the assessment and intervention of family needs (Nicholson and Biebel 2002). Most parents who are mental health consumers do not seek support from their mental health clinicians in their parenting role. Some reasons for this include the fear of being judged as poor or inadequate parents, and fear of losing custody or access to their children (Diaz-Caneja and Johnson 2004). In turn, various barriers have been described for adult mental health clinicians related to difficulties in identifying the parents within their cohort, and incorporating parenting and children’s needs into assessment, support and intervention (Fudge et al. 2004). Locally, the New South Wales (NSW) Government in its policy directive on children of parents with mental illness (COPMI) has highlighted the need for prevention of mental disorders in children, addressing stigma and equity of access to services, and providing integrated services for patients and families (NSW Health 2010). Identification of parents with mental illness is a key part of this policy, and
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the use of specific parts of NSW’s Structured Clinical Documentation (SCD) forms is considered an important tool in such identification. The introduction of an SCD approach is one general approach to raising standards across MH services in NSW (NSW Health 2006). SCD has been shown to improve quality of clinical documentation of key issues such as risk of harm to self (NSW Health 2004) as well as improving clinical confidence, reducing training requirements and a familiar, standardised format leading to improved clinical decision making (Bar-on and Zanga 1996). The system of SCD designed and implemented in NSW MH is the Mental Health Outcomes and Assessment Tool (MHOAT). This was reviewed and the revised SCD was implemented in all Area Health Services (AHS) in 2008 (NSW Health 2008a). Notable in the revision was the modular approach consisting of mandatory and non mandatory modules. An example of the former is the Mental Health Assessment (MHA) module and of the latter the Family Focused Assessment (see ‘‘Appendix’’) (NSW Health 2008b). The FFA is an example of a specific initiative to support clinicians in identifying and supporting COPMI families. It is a two-page document which guides the recording of information covering a number of key domains relating to the potential effects of the parent’s psychiatric symptoms on parenting, indicators of child functioning and potential hazards to child safety and wellbeing, and appraisal of protective and vulnerability factors. Its purpose is to aid the mental health clinician in considering the effects of the patient’s condition on parenting, and vice versa. A second specific initiative to promote family sensitive practice in MH services was the provision of training on the impact of parental mental illness on children using the Crossing Bridges NSW (CBNSW) materials. CBNSW is a locally adapted version of the original British Crossing Bridges training program (Falkov 1998).
Here we report findings of a case note audit examining MH clinicians’ use of relevant components of (MHOAT) SCD regarding identification, assessment and intervention for COPMI families known to selective Community Mental Health Teams (CMHTs) in SWAHS. The timing of the audit enabled comparison of clinical documentation usage and quality before and after case managers received CBNSW training.
Methods At the time of study, public health services in NSW, including Mental Health, consisted of 8 large geographic regions (AHS) and two state-wide entities. In rolling out the CBNSW training, a defined number of one-day training sessions was offered to each AHS on a ‘1st come 1st served’ basis. Funding was for a series of one-day training workshops for each AHS, one of which included the Sydney West Area Health Service (SWAHS). Following NSW Health Service restructure, SWAHS has become the Western Sydney Local Health District (LHD) and the Nepean Blue Mountains LHD. According to the 2006 Census, SWAHS had a population of 1,060,673 (NSW 7,107,512) Sydney West Area Health Service (2011). While SWAHS had pockets of affluence, overall it serves moderate to severe social disadvantage (see Table 1) (Australian Bureau of Statistics 2006). Community MH services were organised across 15 Community Mental Health Teams (CMHTs), based around the boundaries of Local Government Areas. In SWAHS, CBNSW took place on five occasions during August-November 2009. The training commenced 11 months after revised SCD was implemented and included a section on use of the FFA. Adequate staffing levels in Mental Health Services are determined in NSW by the use of the Mental Health— Clinical Care and Prevention Service Planning Model
Table 1 Number of audited files, staffing levels and index of social disadvantage for each CMHT audited CMHT
No. of patients
Staffing levels (% of MH-CCPa) Jan 2009
Staffing levels (% of MH-CCPa) May 2010
Index of social disadvantage decileb
Youth team (18–25 years) A
8
N/A
N/A
5
Youth team (18–25 years) B
2
N/A
N/A
1&5
Case management team A
38
34
17
4
Case management team B
28
43
37
2
Case management team C
14
43
45
9
Case management and acute team A
142
35
26
5
Case management and acute team B
48
26
19
1
N/A = Not available; team leaders were not able to provide this data in the time provided a
Number of staff as a percentage of ideal staffing levels proportional to the population, according to the Mental Health Clinical Care and Prevention (MH-CCP) model (NSW Health 2009)
b
1 = Top 10 % of social disadvantage; 10 = Bottom 10 % of social disadvantage (Australian Bureau of Statistics 2006)
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Files on SCI
Files located
File where consumer was identified as a parent
Time 1
Time 2
N/A
676
98
70
112
182 (33% of files located)
Total number of files audited
PM identification
549 (81%)
N/A
In Time 1 of the audit, file identification varied according the team leader’s discretion.
70 files were identified in T1 and T2. In these cases, the files were not re-audited.
280
117 (61%)
58 (65%)
Total PM identified
175 (63%)
Intervention provided
96 (34%)
P=0.53 (χ2)
Fig. 1 Number of patient files at different stages of the audit
(MH-CCP) (NSW Health 2009). In collaboration with CMHT team leaders this model was used to determine actual staffing levels of the audited CMHTs at the time of the audit, as a percentage of ideal staffing levels. Sample Recruitment Resources prevented an area-wide audit of all 15 CMHTs in SWAHS. Teams were invited to participate by phone and email to the team leaders of all adult (18–65 years) CMHTs in SWAHS explaining the purpose of the audit. The first eight CMHTs whose team leaders responded were
included, with one exclusion due to the absence of any staff participating in CBNSW training. A two-phase recruitment was undertaken at each of two time points (T1 and T2—see Fig. 1). Phase 1 consisted of obtaining a list of all referred and accepted patient/client files (of adults aged 18–65) at each of the two time points and screening for parental status. At T1, files with a completed episode of care between 1/1/2009 and 1/2/2010 were identified by each team leader. At T2 the recruitment procedure was revised utilising central (electronic) identification through the service contact information (SCI) electronic database, for all adult patients with completed
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episodes of care between 1/8/2009 and 23/5/2010. At both time points files were then obtained from records department and each file was examined to determine parental status and presence of dependent children (\18 years). At each time point, phase 2 involved detailed case notes review of patient-parents (obtained from phase 1 screening). A proforma was used to gather more detailed information including family demographics; details about dependent children (number of children, ages, gender and whether they were living with the patient at the time of assessment); information relating to the presenting problem; safety and wellbeing of children; the presence of family supports; parenting difficulties and whether the case manager had inquired but not identified parenting difficulties or children’s needs and use of the FFA. The proforma was based on family-relevant categories and sections from the Modules comprising SCD: the Assessment, Triage, Review, Care Plan Risk Assessment & FFA modules. Patient files were screened carefully across the two recruitment phases to avoid duplication. There was no practical way of checking whether patients were partners of other audited patients. Each case manager was identified by locating their name on the discharge summary or (if no discharge summary), MH worker with most casenote entries. Files were then categorised according to whether the case manager had undergone CBNSW training, and whether the episode of care occurred before, during or after training. A case was deemed to be open during training if the file was open at any time between the dates that all case managers of the patient’s CMHT received training. The audit was approved as a Quality Assurance audit by the Sydney West Area Health Service Human Research Ethics Committee.
Results Identification of Parents A total of 280 files were audited, 175 of which had a parenting issue identified. For the T2 period, 33 % of patients were parents. A variable response from different teams regarding referral number, case ascertainment and casenote location at T1 means that the T1 parent prevalence figure was not robust. The T2 figure of 33 % (182/ 548) is based on a more systematic sample of referrals, and better casenote retrieval. Of the 280 parents, 167 (60 %) had an episode of care of less than 1 month, 71 (25 %) had an episode of care lasting 1–6 months, and 42 (15 %) had an episode of care lasting more than 6 months.
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Quantitative Use of SCD Examining the completion rates of SCD forms (including partial completion), 126 files (45 %) had a MHA form completed during the current episode of care, and 191 (68 %) had either a MHA form or A1 (the original version of the MHA form prior to redesign) completed at any time. 203 files (73 %) had a Triage form completed. Nine files (3 %) had a Family Focused Assessment form. 154 files (55 %) had at least one other form completed that was relevant to the audit (Risk Assessment, Domestic Violence Screen, Review, Care Plan, Consumer Wellness Plan). Demographic Details The age range of parents was 18–59 years (mean of 36.3), 186 of whom were female (66 %). 40 % were married or cohabiting, 35 % single, separated, divorced or widowed and in a quarter of cases marital status was not provided. At T2, 49 % of all patients were male, but only 37 % of patients identified as parents were male. There were 557 children documented in 277 of the 280 files (99 %), with equal gender distribution (212 girls) and gender unrecorded for 25 %. There was a relatively even age distribution, with age undocumented in 44 children (8 %). Residential status of children was recorded for 216 parents (77 %), over half of whom (148 parents) had their children living with them. 52 parents (19 %) did not have children living with them. In 16 files (6 %) residential status was unclear. Documentation of Clinical Need in Families and Service Responses At least one parenting issue was documented in 175 case notes (63 %). The five most common parenting issues were: (1) the parent expressing significant difficulties coping with the parental role (41 %), (2) parents relied on their children for support (29 %), (3) the patient’s illness or family factors impacted negatively on the child’s safety and welfare (27 %), (4) documentation of parenting supports (family and services) (25 %), and (5) aspects of children’s welfare have been considered and appear to be adequate (23 %). Note that often more than one issue was identified in each file. Parenting issues were mentioned as part of the presenting problem in 92 patients (53 % of files with a parenting issue). The 5 most common parenting issues as part of the presenting problem were: (1) Significant difficulties with the parental role (48 %), (2) the patient’s illness or family factors impacted negatively on the child’s safety and welfare (27 %), (3) custody disputes and separation problems were contributing to parental psychopathology (27 %), (4) parental reliance on children for support (21 %), and (5) children with disruptive, oppositional or
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aggressive behaviour were contributing to parental stress (18 %). Interventions relating to parenting issues were documented in 96 files (55 % of files with a parenting issue). The 5 most common interventions were: (1) referral to or liaison with the child protection agency (44 %), (2) referral to early childhood, perinatal, disability, parenting or family support service(s), (3) management of parenting by Mental Health case manager (25 %), (4) recommendation for private psychologist for parent (22 %), and (5) liaison with or referral to patient’s GP or private psychiatrist (14 %). Clinicians appeared more likely to identify and record a parenting issue: • •
•
In mothers compared to fathers (69 vs 49 %, p = 0.001). If children were living with the identified ill parent compared to non-custodial patient-parent (69 vs 38 %; p \ 0.001). In married/defacto parents and separated/divorced parents compared to single parents (68 and 64 vs 33 %, p = 0.001).
The labour-intensive process of ascertaining parental status emphasises the need for more systematic and accessible administrative procedures for documentation of patients who are parents. This finding has implications for all services involved with adults experiencing mental health problems. There is a need for mechanisms to ensure mandatory identification of adult patients who are parents at the point of first contact with services and to ensure that this information is incorporated into clinical work at the outset (Fletcher et al. 2012). Demographics of Children Children of all ages were recorded in this audit, highlighting the need for a developmental approach to cater for the spectrum of presentation. There was a much higher proportion of missing data for children’s gender (25 %) than children’s age (8 %). The SCD sections from which this data was extracted asked specifically for age and not gender, indicating the usefulness as well as limitations of SCD in promoting a comprehensive approach to assessing need. Clinical Implications
The Influence of Training on Case Manager Documentation of Family Needs Eighty-four of approximately 1,100 (McMillan A, personal communication, 2011 May 19) Mental Health Staff from inpatient and community settings completed CBNSW training during August–November 2009. Of these, 25 were case managers of patients audited in the study, accounting for 189 patients (7.6 patients per case manager). A further 18 case managers (not completing training) case managed patients audited in the study, accounting for 91 patients (5.1 patients per case manager). This difference of case manager load was not significant (v2 20.1, p = 0.11). There were no significant differences in case note identification of parenting needs between case managers who received and those who did not receive CBNSW training. There were also no differences in CM recording behaviour prior to and subsequent to training.
There were notable weaknesses in uptake and utilisation of even mandatory modules such as the MHA (completion rate of 45 %). Regarding a specific family (COPMI) focus only 3 % of files had a completed FFA, with no improvement following targeted training. This was despite the fact that CBNSW had been modified to facilitate use of the FFA. Furthermore, even when the forms were completed, there was a high rate of missing data (e.g. child demographics). As the vignettes show, the files that included an FFA had greater potential for documenting parenting issues. It was also difficult to determine whether the gaps in documentation were related to gaps in history taking or gaps in documenting elicited information. Progress notes were audited in a very limited way, and it was therefore also difficult to determine whether the limitations in documentation were general or related to SCD aversion. This has implications for the design and delivery of training.
Discussion
Parenting Needs of Adults Known to CMHTs
Screening and Identification of Patients Who are Parents
Amongst adults known to CMHTs, parenting-related difficulties constituted a considerable proportion of presentations to MH services. Despite being a minimum estimate, approximately two-thirds of files made some reference to parenting issues and child wellbeing and safety. In half these cases, parenting matters contributed directly to the presentation to MH services, reinforcing evidence for links between parenting, mental health and children’s wellbeing
One-third of patients known to CMHTs were parents, highlighting that they constitute an important proportion of the caseloads of staff in community AMH services. This also represents a minimum estimate and is consistent with data reported elsewhere (Fudge et al. 2004).
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Number of files (%)
Parent expressing significant difficulties coping with parental role
71 (41)
Children relied on by parent for support
50 (29)
Child safety and welfare concerns resulting from parent’s illness or family factors
47 (27)
Documentation of parenting supports (family and services)
45 (25)
Aspects of children’s welfare and safety have been considered and appear to be adequate a
40 (23)
The 5 most common parenting issues as part of presenting problem (92/175)
Number of files (%)
Significant difficulties coping with the parental role
44 (48)
Child safety and welfare concerns resulting from parent’s illness or family factors
25 (27)
Custody disputes and separation problems contributing to parental psychopathology
25 (27)
Parental reliance on children for support
19 (21)
Children with disruptive, oppositional, or aggressive behaviour contributing to parental stress
17 (18)
The 5 most common interventions (96/280)
Number of files (%)
Referral to or liaison with child protection agency
42 (44)
Referral to early childhood, perinatal, disability, parenting or family support service(s)
42 (44)
Management of parenting by MH case manager
24 (25)
Recommendation for private psychologist for parent
21 (22)
Liaison with or referral to patient’s GP or private psychiatrist
13 (14)
a
[1 problem documented in casenotes for a number of parents
and safety (Fudge et al. 2004). The audit also shows that when identification and assessment of parenting matters is undertaken and recorded, then intervention does occur. The most common interventions provided by case managers (Table 2) gives some insight into the priorities of case managers who do identify PMs. The most common intervention is liaison with child protection services. Health staff in NSW are ‘mandatory reporters’ of children at risk of harm; therefore the frequency of this intervention may be a reflection that urgent child safety matters do take priority. The next most frequently documented interventions appear to be parentcentred, with less child-centred interventions such as referral to or liaison with a paediatrician, a child and adolescent mental health team or a school counsellor. Considerable potential therefore exists for more proactive efforts in non-mandatory, child-focused parenting issues. Given that the index person is the adult (not the child), MH services are well placed to intervene earlier and more quickly with children if there is systematic identification and screening in place. This is important because substantial early intervention opportunities exist within Adult MH services if children are identified and provided with support according to their level of need (Falkov 2012). Not all children require specialist intervention and there are evidence based interventions available for this cohort of families, especially for facilitating improved communication and explanations
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between parents and children (Solantus et al. 2009; Beardslee et al. 2009). In turn such an approach can reduce the burden on parents and facilitate their own recovery. The audit also highlighted under-identification of parenting issues in males (fathers), parents whose children do not live with them, and single parents. This supports the need for a focus on fathers generally as well as addressing issues of loss for non-custodial parents, especially fathers, and the nature of support required for single parents (Pethick 2011). Further research is needed to examine the types and nature of supports and intervention required for these particular family subgroups (Falkov 2012). Training Needs of MH Clinicians in CMHTs The audit design was not able to adequately test the efficacy of CBNSW training given the low number of participants. A further complication to training quality impact was that many files had no clear documentation of individual case manager. In many files multiple people were involved in a parent’s care, and the discharge person was often a different CM to the one who did most of the case managing. This made it difficult to differentiate the quality of a single case manager‘s documentation and that case manager’s capacity to incorporate CBNSW training into clinical work. Being a naturalistic study that precluded blinding and randomisation
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may also have led to intervention effects on case managers who did not undergo training. Furthermore, it is also likely that a time limited, non recurrent, stand-alone, one-day training program with limited staff coverage was insufficient to demonstrably influence family focused practice in relation to identification and documentation practices. This has important implications for development and delivery of sustainable education & training programs and the need for an overarching training strategy (Maybery and Reupert 2006). Methodological Limitations Whilst the selected CMHTs were not grossly dissimilar to those not included in the audit, the non-random selection of only half the 15 CMHTs in SWAHS indicates the need for caution in generalising the findings. Although there are pockets of affluence in SWAHS, all teams generally serve areas of considerable psychosocial deprivation and are subject to similar workforce and resource pressures with similar training implications (refer to Table 1). A more detailed within-group analysis of staffing and case load in different CMHTs and associated quality of documentation was not within the scope of this paper. No data was gathered for non-included teams. A further selection bias favoured shorter episodes of care, thus focusing more on emergency-type presentations and less on patients that require long-term treatment. Further analysis is required as to whether identification of parenting issues differs for crisis presentations compared to longer-term case-managed patients, and whether the parenting issues and child safety and welfare concerns are similar in these two groups. The first audit round was inconsistent in the way completed episodes of care were identified, and the proportion of case notes that could not be located was high. Hence the robustness of the T1 prevalence figure is uncertain. Looking Ahead The NSW COPMI Framework was published in 2010 (NSW Health 2010) and a local (SWAHS) implementation plan was developed and endorsed in 2011. The audit data helped to shape the local Implementation Plan by quantifying the number of families at risk and by showing that when staff identified adults they were able to specify parenting issues in a substantial proportion of families. In turn this helped to demonstrate the relevance of a family focus within the adult MH service and facilitated endorsement of a set of minimum (family focussed) standards across the service. For example, monitoring of the number of FFAs undertaken each month and setting a target to identify 100 % of referred adults who are parents (by mid 2015).
Modifications have also been undertaken with the electronic patient/consumer activity recording to ensure greater accuracy in capturing the number of adults who are parents, details about their children and the family focussed interventions that are undertaken. An implementation committee with high level representation across the MH service now meets on a regular basis to monitor the implementation Plan and assist with addressing ongoing barriers to family focussed practice. Finally, it is worth noting that the changes that have been undertaken to date have occurred within existing teams without additional resources, demonstrating at least to some degree, more appropriate use of existing resources and, hopefully strengthening the argument for investment of new resources. Acknowledgments The authors are grateful for assistance provided by: Donna Gillies (Senior Research Officer), Robyn Bowcock (Quality Systems Manager), and the COPMI coordinators of Western Sydney Local Health Network (prior Sydney West Area Health Service). Neda Dusevic (Former Project Manager MHOAT, InforMH). Participating Service mangers, Team Leaders and Community Mental Health Teams. Financial assistance was provided in the form of a Fellowship for Advanced Training in Child and Adolescent Psychiatry, funded by NSW Health and administered by the NSW Institute of Psychiatry.
Appendix The FFA is an example of a specific initiative to support clinicians in identifying and supporting Copmi families. It is a two page document which guides the recording of information covering a number of key domains. Page 1 focuses on current identified parent/carer symptoms and behaviours associated with current mental state, insight and judgement, co morbid conditions, and self reported concerns. Each item has a number of prompts to facilitate inquiry and responses can be recorded as present, absent or not known. There a section for the child’s current functioning regarding physical and psychosocial health and development as well as a section for self reported concerns. The final section provides for recording of concerns by others regarding the child’s wellbeing and safety. This includes concerns expressed by relatives, friends or neighbours as well as concerns expressed by staff in other services including teachers. Page 2 provides a summary page for recording current and lifetime risk and protective factors relating to the child, parent/carer and family. It covers a number of key domains in which to consider risk as well as protective factors. These include parent/carer mental health history; drug and alcohol history; family medical history; family of origin (childhood) experiences, parental functioning and social support as well as children’s developmental and personal history, impairments and supports.
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Importantly, it provides an overview section to record a summary of impairment relating to parenting, capacity to undertake daily activities and adverse impacts on the child. The intention is for key information to be collated, analysed and recorded as part of the care planning process. Specific actions related to parental support, child safety and wellbeing can be documented. Clinicians therefore have a structured record of information to inform care planning and decision making which takes account of the interplay of risk and protective factors in individuals and the various family interactions. The FFA is available, along with other MHOAT forms, at http://www.health.nsw.gov.au/policies/ib/2008/ pdf/IB2008_047.pdf.
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