Primary Mental Health Program Guidelines

Primary Mental Health Program Guidelines February 2018 1. Introduction 1 2. Scope of the Guidelines 1 3. Murray PHN Priority Requirements 2 4. Service Principles 3 5. Service Access 5 6. Service approaches 6 7. Organisational requirements 9 8. Primary Mental Health Clinical Care Coordination (PMHCCC) service delivery 10 9. Psychological Therapy Services (PTS) service delivery 14 Addendum: PTS- Child Mental Health 19 Addendum: PTS- Suicide Prevention 27 Addendum: PTS- Aboriginal and Torres Strait Islander 32 Addendum: Qualifications and skills required to deliver services 34 Primary Mental Health Program Guidelines

1. Introduction The Mental Health Commission s Contributing Lives, Thriving Communities Report in 2014 provided key recommendations for future mental health services in Australia. The Australian Government welcomed the findings and recommended a new approach to primary mental health services within a stepped care model. In 2015, the Commonwealth Government tasked Primary Health Networks with commissioning primary mental health services. Two objectives guide this approach: Increase the efficiency and effectiveness of primary mental health and suicide prevention services for people with, or at risk of, mental illness and/or suicide Improve access to the integration of primary mental health care and suicide prevention services to ensure people with mental illness receive the right care, in the right place, at the right time. To implement Murray PHN s stepped model of care program, Guidelines for both Psychological Therapy Services (PTS) and services for people who experience severe mental illness have been revised. These program guidelines have been informed by feedback from clinical leaders in the field and further early soundings with providers to test, monitor and adapt system changes according to capacity during 2017/18. 2. Scope of the Guidelines These guidelines are to be read in conjunction with the Funding Agreements and Deeds of Variation between Murray PHN and the primary mental health service provider. The following services must be provided in line with these guidelines and other legislative requirements: Primary Mental Health Clinical Care Coordination (PMHCCC) Psychological Therapy Services (General and Specialist) It is recognised that this document may be distributed to others, including allied health providers, GPs, and state government health departments and associated services. Primary mental health service providers have some flexibility in how these services are implemented at the local level, and should not rely on this document alone for information on the availability and eligibility of these services in their local area. It is recommended that health care providers contact either Murray PHN or the local service provider that funds the provision of services, for information specifically related to eligibility and availability in the local area. Primary Mental Health Program Guidelines Version 2 (20171112) Page 1 of 37

3. Murray PHN priority requirements Psychological therapy service Commission psychological therapy services for people from underserviced populations to address identified gaps and review access by these populations. Support GPs in their critical role in ensuring people are referred to the right care at the right time. Ensure high level of service quality and the most efficient use of resources. Ensure referral pathways are in place to support clients to seamlessly transition between services as their needs change. Integrate commissioned services with other intervention levels within a stepped care approach 1 Service and clinical care coordination for people with severe mental illness Develop and commission clinical mental health services to support the needs of people with severe and complex mental illness who are best managed in primary health care. Promote better integration of primary care services with community-based, private psychiatry, state mental health services, Partners in Recovery (PIR) and the emerging National Disability Insurance Scheme (NDIS). Engage with the private mental health care sector to ensure links are in place with private hospitals and psychological services to support care coordination. Ensure referral pathways are in place to enable and support patients in seamless transition between services as their needs change. That future models of care consider the impact of severe mental illness on physical health. The mental health needs of Aboriginal and Torres Strait Islander people are significantly higher than those of other non-indigenous Australians, and thus all services must be culturally safe and competent and some services may need specific targeting 2. Consumer and carer engagement and participation The government s national guidelines for flexible and locality-based mental health service design recognises the rights of clients and carers and ensures relevance to local communities. There is a mandate for consumer and carer engagement and participation to: Establish and foster collaborative partnerships with consumers and carers throughout the commissioning cycle. Apply principles of experience-based co-design, with a focus on a recovery-orientated approach. Recognise the rights of consumers and carers and seek to recognise and reduce stigma and discrimination in primary health care settings 3. Primary healthcare coordination and integration Integration between primary mental health providers, primarily GPs, other mental health clinical services and psycho-social supports, is necessary to support individual need and planning of integrated and coordinated care. Primary healthcare providers are expected to: Design and implement a model of care that is patient-centred and is integrated with the local area health system, particularly general practice. 1 PHN Primary Mental Health Care Flexible Funding Pool Implementation Guidance: Psychological therapies provided by mental health professionals to underserviced populations, 2015. 2 PHN Primary Mental Health Care Flexible Funding Pool Implementation Guidance: Primary Mental Health Care Services for People with severe mental illness, 2015. 3 PHN Primary Mental Health Care Flexible Funding Pool Implementation Guidance: Consumer and carer engagement and participation, 2015. Primary Mental Health Program Guidelines Version 2 (20171112) Page 2 of 36

Seeks to strengthen the primary care service system to gain greater service coordination and system integration. Support GPs in their role to ensure people are referred to the right care at the right time. Collaboration and continuous improvement Collaboration with Murray PHN is supported through the commissioning principles that recognise the value of enduring partnerships with the health service system and our shared accountability for innovation, quality and system improvement. By entering into an agreement with Murray PHN, service providers will: Share performance and effectiveness information and evidence to support the design and continuous improvement of services to meet identified community needs and priorities. Work collaboratively to measure outcomes based on the Murray PHN Quadruple Aim model that includes population health outcomes, patient experience, workforce health and sustainability and cost per capita (value for money). 4. Service principles Murray PHN expects primary mental health services to be delivered within the following approaches and principles: Person centred holistic approach Co-design and the lived experience Stepped care approach Integrated system of care Team-based shared care Person centred holistic approach Cultural safety Local service delivery Evidence based Primary mental health care that is person centred, and recognises that illness, health and wellbeing are influenced by a broad range of social, cultural, economic, psychological, and environmental factors at every stage of life. Care is provided with a holistic framework and system that is flexible and draws upon a combination of different interventions and health partners 4. Person-centred care acknowledges the person s central role in their care, fostering a sense of responsibility for their own health and promoting self-management. This includes supporting and encouraging the individual to access a range of self-guided tools and resources as alternatives or adjuncts to clinician-led, face to face interventions. Services are also expected to be family-sensitive and provide family-friendly environments. The needs of a client s family, especially dependent children should be considered in service delivery. Stepped care approach The stepped care model is an integral aspect of a person-centred, effective and efficient system that is used to organise the provision of services and to help people with mental health disorders, their families, carers and healthcare professionals to choose the most effective interventions. Stepped care is defined as an evidence-based, staged system comprising of a hierarchy of interventions, from least intensive to most intensive, matched to the individual s needs. While there are multiple levels within a stepped care approach, they do not operate in silos or as one directional steps, but rather offer a broader service spectrum within an integrated care pathway. Service users may begin their journey at any step of the pathway, in accordance with their needs. 4 Joint Commission Panel for Mental Health, Guidance for commissioning public mental health services, UK 2012 Primary Mental Health Program Guidelines Version 2 (20171112) Page 3 of 36

Diagram 1: Stepped care. Australian Government guidelines The role of the GP in stepped care In a stepped care approach, GPs undertake their initial assessment to determine the most appropriate treatment response. GPs provide the clinical leadership and with the client, help identify other members of the care team to support recovery. GPs are usually the gateway to other service providers and therefore support the identified health needs that in turn inform the most appropriate pathways. Integrated system of care Primary mental health care that moves from isolated providers and intervention to a health care system that, through partnerships with community and service providers across the health care system, enhances care, improves quality and avoids duplication of effort. Services providers will work together to develop localised pathways, use innovative thinking to close systems gaps and reduce inefficiencies. Team-based shared care The client and carer (where appropriate) are key members of the shared care team. A client s team can consist of general practitioners, psychiatrists, mental health nurses, psychologists, counsellors, social workers, occupational therapists, support facilitators, vocational support workers, housing support workers, other community support workers, peer workers, carers, family and friends. PTS or PMHCCC may form one aspect of a client s shared care, alongside other team care. The team might be virtual (e.g. from different disciplines, agencies and/or locations) and across various funding sources to optimise integrated care and meet the holistic needs of the client. Organisations are encouraged to consider integrated models that use existing service structures and blended funding streams and models including the Medicare Benefits Scheme (MBS). It would be expected that a range of complementary skills and scopes of practice exist within a care team. The team-based approach also strengthens clinical governance through the inclusion of regular peer support, clinical supervision and team case review. Co-design and consumer and carer participation The voice of consumers and carers is a fundamental principle of Murray PHN s primary health services. Service providers should aim to work with clients and carers through co-design as part of localised service development, delivery, monitoring and evaluation. Primary Mental Health Program Guidelines Version 2 (20171112) Page 4 of 36

Cultural safety The National Strategic Framework for Aboriginal and Torres Strait Islander Peoples Mental Health and Social and Emotional Wellbeing 2017-2023 is a critical part of ongoing reform to the mental health system and interconnected with many strategic responses to Aboriginal and Torres Strait Islander health 5. Services must work under this framework and ensure they have a clearly articulated strategy for providing cultural safety in the delivery of services for Aboriginal and Torres Strait Islander peoples. Services for the CALD communities must be delivered in keeping with the statement by the Australian Government Department of Health. Services for lesbian, gay, bisexual, transgender and intersex (LGBTI) are delivered in keeping with the with the statement by the Australian Government Department of Health. Local service delivery Service delivery arrangements will be localised according to the community s needs. Services should be delivered from settings which are accessible for clients and appropriate for the service being provided. The mental health service areas should inform service planning and delivery, but not restrict a client from receiving services in their preferred location due to their postcode. Evidence-based practice Evidence-based practice (EBP) is 'the integration of best research evidence with clinical expertise and patient values' which, when applied by practitioners, will ultimately lead to improved patient outcome. Treatment decisions need to be based on evidence and guidelines supported by clinical research. Practitioners invest in ongoing professional development and maintain currency of practice in line with up-to-date and latest evidence and treatment modalities. Linkages with specialist services are established and pathways where appropriate to support people with more complex presentations. 5. Service access Referral pathways Service providers are required to develop and promote local service access arrangements to optimise referral pathways and better support service access for vulnerable populations. Ongoing collaboration with general practitioners and local services who support vulnerable populations is expected. Clients needs must be considered within a stepped care approach. Referral and intake tools and protocols must be used to ensure that: people are referred to appropriate services resources are effectively targeted within the service area duplication is avoided expected levels of demand are effectively managed. Murray PHN will also introduce and operate an interim referral and advisory service to support the transition for referrers, particularly GPs seeking assistance to navigate the level and type of service available from local service providers. 5 National Strategic Framework for Aboriginal and Torres strait Islander Peoples Mental Health and Social and Emotional Wellbeing 2017-2023, Commonwealth of Australia 2017 Primary Mental Health Program Guidelines Version 2 (20171112) Page 5 of 36

Referral source and Mental Health Treatment Plans Generally, referrals should be provided by the client s GP or psychiatrist. A Mental Health Treatment Plan (MHTP) is expected at the point of referral however no individual should be restricted from the program due to the absence of a MHTP. Where there is no MHTP the service provider should support the client to be seen by a GP/psychiatrist to provide a Mental Health Treatment Plan within two weeks of treatment commencing (four weeks in rural areas). Where a person has been referred to PTS because they are at risk of, or have attempted, suicide or self-harm, a Mental Health Treatment Plan is not required. A Mental Health Treatment Plan is required for children. Where a diagnosis of a mental illness does not exist, the referring practitioner should document that the child is assessed as being at risk of developing a mental disorder in the Mental Health Treatment Plan. Managing demand Service providers will ensure they have an appropriate demand management strategy in place. Service providers should consider support service options such as e-mental health (e.g. Mindspot) and tele psychiatry during these periods. Service providers are encouraged to consider extended operating hours to improve access, and to work with clients to identify appropriate service delivery arrangements that support the individual needs of the person. The use of client reminder and recall systems is encouraged to maximise client engagement and appointment attendance. 6. Service approaches Recovery-oriented goal planning The recovery-oriented goal plan developed to support the promotion of recovery from mental illness, is underpinned by the National Framework for Recovery-Oriented Mental Health Services 2013. Shared care health records Service providers are encouraged to: a) Register to participate in the My Health Record system at myhealthrecord.gov.au My Health Record is a secure online summary of an individual s health information and aids communication for the person and their care team. b) Advise and support the client to use the personally controlled My Health Record. Electronic shared care tools are also encouraged for consideration by the service provider and their stakeholders to optimise shared care arrangements. Primary Mental Health Program Guidelines Version 2 (20171112) Page 6 of 36

Delivery modalities It is expected that a range of modalities, in individual and/or group mode, would be used within these services to enable timely support, especially in a rural and remote settings such as: Face to face i.e. in clinics, clients homes, or other community based settings Telephone Video conferencing Digital mental health. Digital resources The use of digital mental health resources (e-mental health) can benefit clients and complement services across the stepped care approach, including for people living with severe mental illness. Types of e-mental health include information, self-directed support and tele-psychiatry. Places to access digital resources include but are not limited to: Head to Health (digital mental health gateway) emhprac.com.au Crisis support The service provider must ensure there is a crisis support mechanism for individuals being provided with treatment to cover their needs after hours, and for the allied health professionals who provide treatment. Appropriate after-hours crisis support contact numbers and details are to be given to each individual provided with services. Clinical practice guidelines Care must be provided according to the plan and the relevant clinical guidelines for the treatment of that disorder. Examples of clinical practice guidelines can be found at the Royal Australian and New Zealand College of Psychiatrists. Murray HealthPathways is available to support clinical practice, care coordination and local referral pathways. This is a dynamic decision support tool with local referral pathways systematically published and refreshed with input from local clinical working groups. Client data and reporting The Australian Government s Department of Health has established the Primary Mental Health Care Minimum Data Set (PMHC-MDS). The PMHC-MDS requires providers to capture client and service delivery data. The PMHC-MDS provides the basis for PHNs and the Department of Health to monitor and report on the quantity and quality of service delivery, and to inform future improvements in the planning and funding of primary mental health care services funded by the Australian Government. Specific details on PMHC-MDS are available at pmhc-mds.com. Murray PHN uses a cloud based client management system to capture client reporting data. Murray PHN User guides to PMHC-MDS are available on our website. Primary Mental Health Program Guidelines Version 2 (20171112) Page 7 of 36

Client consent and privacy Consent to treatment The service provider must obtain Informed consent from clients or guardians before any intervention is commenced. The service provider must ensure that, when obtaining client or guardian consent to services and documenting that consent, it is done so in accordance with the clinical governance arrangements. Consent to share information Service providers must ensure that permission is obtained from the client to share information with Murray PHN and de-identified information with the Department of Health. Resources for clients and service providers about consent and privacy are available on Murray PHN s website. Measuring outcomes Outcome measures should be used as clinical tools to establish a benchmark and track a client s progress. The PMHC-MDS mandates the Kessler Psychological Distress Scale K10+ (in the case of Aboriginal and Torres Strait Islander clients, the K5) as well as the Strengths and Difficulties Questionnaires when working with children and youth. One of these three outcome measures should be used at a minimum at the beginning and end of service, but should be considered more frequently from a clinical perspective. Client feedback and complaints Consumer feedback, complaints and compliments are a valuable resource and should be encouraged in all aspects of the service. Service providers are required to seek client feedback as detailed by Murray PHN and the Department of Health. Service providers must have a complaints mechanism in accordance with section 1.16 of the National Standards for Mental Health Services. This mechanism must be documented in a plain English brochure and, as appropriate, in other languages. All people who are provided with services are to be provided with a copy of the complaints mechanism brochure. Service evaluation By entering into a partnership with Murray PHN, service providers will work with us by contributing to information exchange and building knowledge about the characteristics of the health service system, community context and population health outcomes that inform and are influenced by the proposal. Monthly dialogue with successful bidders is an important process for Murray PHN to work with the service system and build shared knowledge and accountability for innovation, quality and system improvement. Performance and effectiveness indicators comprise an important part of the ongoing dialogue as does also the Quadruple Aims as outlined in the Murray Health Systems framework, namely improved: Population health outcomes Patient experience Workforce health and sustainability Cost per capita. Primary Mental Health Program Guidelines Version 2 (20171112) Page 8 of 36

7. Organisational requirements Service providers Murray PHN will commission suitably qualified service providers to deliver services, through a transparent and robust procurement process. Service providers may include: general practices private psychiatry practices private and Non-Government Organisations (NGOs) mental health services Aboriginal and Torres Strait Islander Primary Health Care Services funded by the Australian Government through the Indigenous Health Division community health services public health services Workforce scope for PMHCCC A range of skills are required within a team for this program. A mental health nurse credentialed with the Australian College of Mental Health Nurses is a required team member for the provision of PMHCCC. Other team members may include: mental health social worker mental health occupational therapist psychologist exercise physiologist mental health support facilitators mental health peer worker (the development of a peer worker role is encouraged) dietician. Team members are required to work within their role and their scope of practice. Further information on requirements is detailed in Addendum Qualifications and Skills. Workforce scope for PTS Allied health professionals including psychologists, and appropriately trained nurses, occupational therapists, social workers may deliver services under the PTS General and the PTS Specialist program streams. Aboriginal and Torres Strait Islander health workers may deliver services under PTS- Aboriginal Torres Strait Islander program stream in keeping with their qualification. Specialist training requirements must be met for the provision of PTS relating to suicide prevention and child mental health services as detailed in the relevant addendums. Provisionally registered allied health professionals are not eligible to provide suicide prevention service and services for children. Further information on requirements is detailed in Addendum Qualifications and Skills. Primary Mental Health Program Guidelines Version 2 (20171112) Page 9 of 36

Standards of practice In providing the service, an organisation must maintain practice consistent with standards articulated in the National Standards for Mental Health Services 2010 6 and the National Practice Standards for the Mental Health Workforce 2013 7 and all other relevant standards and legislative/regulatory requirements and within the Victorian Clinical Governance Framework. Clinical governance The service provider must establish and maintain appropriate clinical governance and quality assurance arrangements for all components of the service as specified in the contract terms and conditions. Service providers are expected to work under the Victorian Clinical Governance Framework (2017) that describes the integrated systems, processes, leadership and culture that are at the core of providing safe, effective, accountable and person-centred healthcare, underpinned by continuous improvement 8. Clinical supervision Clinical supervision is critical for ensuring that services delivered by mental health practitioners have the required clinical governance for them to provide services of best practice for clients, and also to support the mental health practitioners to maintain personal and professional resilience and wellbeing. Clinical supervision should be provided in keeping with the Victorian Clinical Governance Framework and the requirements of the mental health practitioners professional discipline standards of practice, for example please see the Australian College of Mental Health Nurses, and the Australian Association of Social Workers. 8. Primary Mental Health Clinical Care Coordination (PMHCCC) service delivery Service aims The PMHCCC has the following aims: Improve the care coordination and service integration for people living with severe mental illness Reduce the likelihood of unnecessary hospital admissions and readmissions for people living with severe mental illness To work in partnership with people living with severe mental illness in their recovery and during periods when greater clinical support is required Improve physical health of clients through assessment, management and onward referral arrangements for all clients. Functions of the service Providing clinical care coordination for clients with severe mental illness by: establishing a therapeutic relationship with the client liaising (with client consent) closely with family, carers, employers, educators or other key supports for the client as appropriate regularly reviewing the client s mental state and assisting with necessary emergency/safety responses 6 National Standards for Mental Health Services 2010, Commonwealth of Australia, 2010. 7 National Practice Standards for the Mental Health Workforce 2013, State of Victoria, Department of Health 2013 8 Victorian Clinical Governance Framework, State of Victoria, Department of Health and Human Services, June 2017 Primary Mental Health Program Guidelines Version 2 (20171112) Page 10 of 36

supporting the client and GP/psychiatrist with medication management actively monitoring physical health care and providing onward referrals, information and strategies to support improved physical health outcomes. shared care planning and coordinating services maintaining links and undertaking case conferencing with general practitioners (GPs), psychiatrists and allied health workers, including psychologists, mental health occupational therapists and accredited mental health social workers (health professionals may be eligible to claim case conferencing items under the MBS where they have a Medicare provider number) assisting with onward referrals providing links with programs established to support people with complex mental illness and other needs, for example Partners in Recovery, NDIS and Personal Helpers and Mentors Service assisting with connections to local community activities and groups to optimise meaningful activity. A minimum expectation of clinical care coordination includes: Mental health treatment plan incorporates assessment, recovery goals and care plan Clinical monitoring including medication management and periodic case review Referral and care coordination Physical health assessment and plan Discharge planning. Client entrance criteria To be eligible, each of the following criteria must be met: the client has been diagnosed with a mental disorder according to the criteria defined in the World Health Organisation Diagnostic and Management Guidelines for Mental Health Disorders in Primary Care: ICD 10 Chapter V Primary Care Version, or the Diagnostic and Statistical Manual of Mental Health Disorders - Fifth Edition (DSM-5) the client s illness is significantly impacting their social, personal and work life the client has been to hospital at least once for treatment of their mental disorder, or they are at risk of needing hospitalisation in the future if appropriate treatment and care is not provided the client has given permission for referral to the program. Priority populations The following populations have been identified as further marginalised and at-risk and may have greater barriers to access. Referral pathways should consider these priority populations to optimise service access that may be more challenging: people experiencing, or are at risk of, homelessness Culturally and Linguistically Diverse (CALD) communities Aboriginal and Torres Strait Islander people people with intellectual disability. National Disability Insurance Scheme (NDIS) The NDIS provides psychosocial support for people living with a disability. Participants of the NDIS are not precluded from receiving PMHCCC. Client exit criteria Support provided under PMHCCC targets clients with severe mental disorders during periods of significant disability. A client should exit the program when they do not require the level of support as outlined in this document. Primary Mental Health Program Guidelines Version 2 (20171112) Page 11 of 36

In order to ensure best practice in client demand management, the service provider must undertake a periodic (recommended six-monthly) review to identify clients who no longer meet the Guidelines for receiving the service. A client s episode of care will conclude when: a) they have achieved their recovery goals and/or their mental illness no longer causes significant disablement to their social, personal and occupational functioning b) they no longer need the clinical services of the program. Treatment planning and monitoring A Team Care Plan that is based on the MHTP should be developed within the first month of the service. The development of this plan should include the client, any nominated supports, the GP/psychiatrist and the team members. The involvement of the GP or psychiatrist in the Team Care Plan could be facilitated through: The use of Chronic Disease Management (CDM) MBS items 9 The use of the four week MHTP review MBS item. The format of the Team Care Plan could use the CDM Team Care Arrangements (TCAs) templates. The care plan should include: agreed levels of contact that meet the client s individual clinical requirements (this may include telephone contact). recovery oriented goals team members team responsibilities that include actions to be taken by the client. regular review. Shared care with Specialist Clinical Services If a client s needs increase and they require support from Specialist Clinical Mental Health Services (Area Mental Health), clinical care responsibilities are transferred however, linkages should be maintained for service continuity and to support effective discharge planning. Interventions It would be expected that a range of interventions are provided by the care team within the program scope. These interventions might include, in individual and/or group settings: Psycho-education Liaison and support for client e.g. family, carers, employers, educators and/or other professionals Medication management Liaison, networking, collaboration and managing referral to other services Advocacy Addressing/managing co-occurring conditions Peer support 9 Chronic Disease Management Primary Mental Health Program Guidelines Version 2 (20171112) Page 12 of 36

focussed psychological strategies including: Acceptance and Commitment Therapy Cognitive Behavioural Therapy Dialectical Behaviour Therapy Brief Solution Focussed Therapy Motivational interviewing Narrative Therapy Trauma informed and responsive approaches Suicide prevention strategies such as Safety Plans Physical health assessment and intervention. Physical health assessment and intervention The integration of physical health and mental health is a key element of this service. The Physical Health Assessment Tool and the Physical Health and Overall Wellbeing Resource Book have been developed through Murray PHN s Partners in Recovery program and should be used within this service. These resources are located at murrayphn.org.au/portfolio-view/mental-health-resources. Levels of support The service would be expected to assist clients who require varying levels of support that fall broadly into these two areas: Monitoring - clients in this group include individuals with severe mental disorders whose clinical symptoms are well controlled but who would be at risk of relapse without ongoing clinical supervision (e.g. clients within the service who have stepped down but would benefit from periodic clinical monitoring). Regular support - clients in this group will have active symptoms which can only be well controlled with regular clinical contact and need close monitoring to prevent deterioration. This may include clients who have persistent or fluctuating clinical symptoms, despite active treatment and are at risk of hospitalisation or further deterioration if not actively managed. Clinical case review A client s treatment plan should be reviewed every three months within a clinical case review process. A clinical case review involves an all of team review (including the client, any nominated supports, the GP/Psychiatrist and the client s other team members). The service provider must provide regular reports to the GP/psychiatrist following any clinical case review, subject to the consent of the client. Organisations are expected to have an effective clinical case review framework that is supported by effective clinical supervision within the Victorian Clinical Governance Framework (2017) 10 as detailed in the clinical governance section of these guidelines. 10 Victorian Clinical Governance Framework, State of Victoria, Department of Health and Human Services, June 2017 Primary Mental Health Program Guidelines Version 2 (20171112) Page 13 of 36

9. Psychological Therapy Services (PTS) service delivery Service aims Psychological Therapy Services (PTS) have the following aims: produce better outcomes for individuals with common mental disorders through offering evidence-based, short-term psychological interventions within a primary care setting target services to those individuals requiring primary mental health care who are not likely to be able to have their needs met through Medicare-subsidised mental health services complement other fee-for-service programs and address service gaps for people in particular geographical areas and populations offer referral pathways for general practitioners (GPs) to support their role in primary mental health care offer non-pharmacological approaches to the management of common mental disorders promote a team approach in the management of mental disorders that promotes and supports the Stepped Care Model. Functions of the service The Psychological Treatment Services (PTS) is a primary mental health service funded by the Australian Government Department of Health to enable access to effective, low cost treatment for people with a mental illness who may not otherwise be able to access services. PTS provides for short term mental health services for people with mental disorders through fundholding arrangements administered by Murray PHN. Primary Mental Health Program Guidelines Version 2 (20171112) Page 14 of 36

Priority PTS targets people who experience mild to moderate mental illness from underserviced populations, where there are barriers to accessing Medical Benefits Schedule (MBS) based psychological intervention. People who have attempted, or who are at risk of, suicide or self-harm (but not acute or at immediate risk) are also considered eligible for PTS. PTS services is divided into two categories (Generalist and Specialist) and five streams. Specialist PTS These services are targeted to specific underserviced populations as described by the stream: 1. PTS - Child Mental Health (for children under the age of 12 years with, or at risk of, developing a mental disorder) 2. PTS - Aboriginal and Torres Strait Islander (for Aboriginal and Torres Strait Islander people) 3. PTS - Suicide Prevention (for people who have self-harmed or attempted suicide or are at risk of suicide) 4. PTS - Perinatal Depression (women with perinatal depression). Generalist PTS 5. PTS - General These services are targeted to the following cohorts: people who are less able to pay fees people living in rural and remote communities people experiencing, or at risk of, homelessness Culturally and Linguistically Diverse (CALD) communities People with intellectual disability. PTS and Better Access PTS is different to the Better Access Program. The Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative includes a range of Medicare rebateable services for people with a diagnosed mental disorder, including psychological services provided by appropriately qualified psychologists, social workers and occupational therapists. The Better Access Initiative is delivered under Medicare regulations whereas PTS is delivered through a fundholding arrangement where allied health professionals are salaried or subcontracted to provide mental health services. PTS also offers a broader range of service providers compared with Better Access, such as mental health nurses and Aboriginal and Torres Strait Islander health workers. The referring clinician decides based on a range of factors, such as priority populations, workforce availability, and the client's ability to contribute to the cost as to whether to refer a patient to Better Access or PTS. However, it should be noted that individuals should only be referred to one of these Programs in any calendar year. Primary Mental Health Program Guidelines Version 2 (20171112) Page 15 of 36

Client entrance criteria To be eligible for PTS, individuals need to have a clinical diagnosis of mental illness. The definition of mental illness (mental disorder) is based on the Department of Health s Better Outcomes in Mental Health Care Program: A mental disorder may be defined as a significant impairment of an individual s cognitive, affective and/or relational abilities which may require intervention and may be a recognised, medically diagnosable illness or disorder this definition is informed by the World Health Organisation, 1996, Diagnostic and Management Guidelines for Mental Disorders in Primary Care: ICD - 10 Chapter V Primary Health Care Version. The short term, goal oriented, psychological strategies services that PTS provides are of most therapeutic value to individuals with common disorders of mild to moderate severity. However, individuals with more severe illness whose conditions may benefit from focussed psychological strategies may also be provided with PTS. Clinical staging will also be used to ensure that PTS is appropriate to the client s need within the stepped care approach. It is the role of general practitioners (GPs) to diagnose individuals, and for those who have a mental illness document this in a Mental Health Treatment Plan, to assess whether they would benefit from a short term psychological intervention. Children For PTS - Child Mental health services only, a provisional referral may be made for a child by their school, or maternal child health nurse; however, a GP is still required to provide a Mental Health Treatment Plan (MHTP) within two weeks of treatment commencing (or four weeks in rural areas). Referral may be made be received directly from a Psychiatrist or Paediatrician without a MHTP, but it is recommended that linkages are made with the treating GP as the central care coordinator in the care team. For the purposes of PTS, children are defined as being 11 years of age or under (or up to and including 15 years of age in exceptional circumstances, where clinically needed and appropriate). Women with perinatal depression Obstetricians and maternal and child health nurses may refer women to the PTS - Perinatal Depression Initiative. However, the individual must have a Mental Health Treatment Plan prepared in consultation with a GP as soon as possible, preferably within two weeks of the first session or four weeks in a rural and remote area, or as soon as practical where access to GPs is not readily available. People at risk of suicide or self harm People who have been referred because they have attempted or are at risk of attempting suicide or self-harm do not require a diagnosis of a mental disorder to be eligible for PTS. Rural/remote Many areas within Murray PHN are classified under the Modified Monash model as MM5. This describes areas that have a population less than 5,000. MM5 areas are considered as rural/remote for the purposes of eligibility for PTS. Primary Mental Health Program Guidelines Version 2 (20171112) Page 16 of 36

People who are experiencing, or at high risk of, homelessness Access to services for this priority group may include outreach services (including mobile clinics ), provisional referrals to PTS before GP assessment and liaison with local NGOs supporting homeless individuals. National Disability Insurance Scheme (NDIS) The NDIS provides psychosocial support for people living with a disability. Participants of the NDIS are not precluded from receiving PTS. However, if a participant s package involved psychological treatment services they may not be deemed in the eligible underserviced group. Number of sessions and clinical case reviews The number of PTS sessions that a client can access in one year is not limited, however clinical staging and a clinical review is expected within the following aspects: A recovery oriented goal plan is expected by the end of the third session. On completion of the initial course of six sessions (and any subsequent set of six sessions), the allied health professional is to provide a written report to the referring medical practitioner. The written report is to include information on assessments carried out, treatment provided, the individual s outcomes and recommendations on future management of the individual s mental health. A clinical case review should occur after the sixth session (and if required 12 sessions, 18 sessions, etc) to consider goals, achievements and receive peer/ supervisor input into clinical approach. A clinical case review involves an all of team review (including the client, any nominated supports, the GP/Psychiatrist and the client s other team members). Unless the individual is being provided with a new referral for a different condition, this is considered to be a continuation of the original episode of care and is not to be recorded as a new episode of care. Organisations are expected to have an effective clinical case review that is supported by effective clinical supervision within the Victorian Clinical Governance Framework (2017) 11 as detailed in the clinical governance section of these guidelines. Interventions The services covered are psychological interventions that have demonstrated the best research evidence of clinical effectiveness for short term treatment of mental disorders, such as cognitive behavioural therapy. These interventions (focussed psychological strategies) include, in individual and/or group mode: Psycho-education Advocacy Peer support Acceptance and commitment therapy Cognitive behavioural therapy: o o o o Behavioural interventions Behaviour modification Exposure techniques Activity scheduling 11 Victorian Clinical Governance Framework, State of Victoria, Department of Health and Human Services, June 2017 Primary Mental Health Program Guidelines Version 2 (20171112) Page 17 of 36

Interpersonal therapeutic strategies (especially for depression) Dialectical behaviour therapy Brief solution-focussed therapy Motivational interviewing Skills training Problem solving skills and training Anger management Social skills training Communication training Stress management Parent management training Interpersonal therapeutic strategies (especially for depression) Narrative therapeutic strategy. Emphasises the changes that can be brought about in people's lives through particular telling and retellings of the stories of their life, understanding these stories and re-authoring them in collaboration between the clinician and the client. This is a particularly useful and beneficial strategy for Aboriginal and Torres Strait Islander populations. Trauma-informed and responsive approaches Relaxation and mindfulness strategies (including progressive muscle relaxation, controlled breathing) Suicide prevention strategies such as Safety Plans (e.g. Beyond Now by beyondblue) Physical health assessment and intervention Liaison, collaboration and managing referral to other services. It is clear from the recommended list of evidence-based, focussed psychological interventions that all allied health professionals must have undertaken rigorous training and be competent in the delivery of these therapeutic techniques when treating people with mental disorders. Interventions for children Pre-adolescent children with mental health problems require special psychological treatment options. The most common treatment option available is cognitive behavioural therapy (CBT) which, in its standard form, requires a level of cognitive development which is generally not achieved until adolescence. For pre-adolescent children, CBT needs to be specially modified and other psychological therapies are required for common childhood mental health problems such as Attention Deficit Hyperactivity Disorder, conduct disorder, oppositional defiant disorder, anxiety and depression. These therapies can be provided through any PTS stream. However, appropriate psychological treatment options for pre-adolescent children sometimes involve therapies which involve the whole family. This may include family-based therapies such as behavioural therapy, and parent training in behaviour management, which entail working closely with parents and families; interventions more closely aligned with PTS - Child Mental Health. It is acknowledged that as these treatment options are not generally part of the standard training of allied mental health service providers, it is the expectation that clinical staff work within their scope of practice, and where indicated, provide a supported referral to a more appropriate service. It is acknowledged that within the clinical disciplines approved to provide PTS - Child mental health interventions, not all will have had these treatment options as part of their standard training. PTS does not fund allied health service providers to undertake such training. Primary Mental Health Program Guidelines Version 2 (20171112) Page 18 of 36

Involvement of parents, guardians or other family members in treatment should also be considered when treating a child where this involvement is appropriate. Parents, guardians or other family members may attend treatment sessions where the individual is a child (and where the child is the person with a Mental Health Treatment Plan) as long as: the allied health professional is comfortable with more than one person being in the room; this is not detrimental to treatment of the client; and the primary focus of the session is treatment of the child. It is expected that the child will be present for these sessions, except in those circumstances where it is not clinically appropriate. Addendum: PTS- Child Mental Health Purpose of the addendum This document provides information specific to PTS - Child Mental Health and builds on the information available in other sections of the Primary Mental Health Operational Guidelines. This addendum is designed for use as a guide by service providers contracted for the delivery of PTS - Child Mental Health. Service providers should use this information, in conjunction with the Primary Mental Health Operational Guidelines and information in their Funding Agreement, to guide their practice. This addendum is predominantly based on the Commonwealth Government s operational guidelines for the Access to allied psychological Services (ATAPS) program Child Mental Health Service. Service aims of PTS - Child Mental Health PTS - Child Mental Health funds the provision of short term mental health services for children, under the age of 12 years, presenting with mental disorders through fund-holding arrangements administered by Murray PHN. Children who have, or are at risk of, developing a mental, childhood behavioural or emotional disorder can receive treatment through the Specialist PTS Program, known as PTS - Child Mental Health. The objective of PTS - Child Mental Health is to provide eligible children with evidence-based, shortterm psychological strategies within a primary care setting. The psychological services and interventions must be relevant to infants and children with mental, emotional or behavioural disorders, and to their families or to other individuals having responsibility for the child. Service providers should ensure service delivery mechanisms underpinning PTS - Child Mental Health contribute to the overall PTS objectives, as well as PTS - Child Mental Health objective through: establishment and maintenance of appropriate referral pathways and linkages with government and non-government stakeholders at the community level (including those outside of the clinical mental health system) provision of efficient and effective services, that are managed within the overall capacity of the service provider to meet demand for services Primary Mental Health Program Guidelines Version 2 (20171112) Page 19 of 36