Abstract
Keywords
While the outcome of a mental illness is affected by the availability of treatment [1], evidence suggests that people have difficulty gaining access to specialist mental health services [2, 3]. Mental health professionals often make decisions about who will receive available treatment. Processes are routinely developed to ensure that only those people who need specialist mental health care gain access to the mental health system.
The duty/triage system is the entry point to specialist public mental health services in Australia. The clinicians working in the duty/triage system make daily decisions regarding the allocation of resources. Tobin et al. [4] identified three functions of an entry system to a wellorganized mental health service. They are to:
– prioritize referrals based on urgency;
– direct resources to manage emergencies quickly; and
– reduce unnecessary use of resources by limiting the inappropriate use of services.
Little attention has been given to the role, function or effectiveness of duty/triage systems despite their role in mediating access to mental health services. As well, duty/triage systems are relevant to understanding the process and barriers to care in any locality and to understanding the unmet need for services, even though system variables do not account for the extent and variation of unmet need in the community [5].
The purposes of this study are (i) to describe the duty/ triage system within a public area mental health service (AMHS) in Melbourne, and (ii) to investigate the factors that influence the decision to organize a comprehensive assessment for a person in contact with the duty/triage system.
Service description
The AMHS is located in inner Melbourne, and provides specialist adult (i.e. between ages of 18 and 65) mental health services to a population of over 200 000 people. The population in the catchment area is diverse. Some localities have significant levels of socioeconomic disadvantage and high numbers of homeless people while other areas are relatively affluent. The AMHS provides acute inpatient beds, crisis assessment and treatment service (CAT), case management, mobile intensive case management, a long-term community residential rehabilitation programme and several specialist statewide services. These are located and managed by a general hospital with University affiliations. A single Emergency Department in the general hospital services the area.
During business hours (Monday to Friday, 09.00 to 17.00 hours) a specialist mental health worker (psychiatric nurse, social worker, psychologist or occupational therapist) is available at each of the two community mental health clinics. This duty worker is rostered to respond to all referrals for a specified time period as a component of a broader role as a case manager or crisis team worker.
Outside normal business hours a specialist mental health triage worker is located in the Emergency Department of the general hospital. Any contacts with the Emergency Department during business hours are referred to the mental health clinic. Triage workers respond to all referrals from the Emergency Department and to telephone enquiries directed by the hospital switchboard. Triage workers are allocated from clinicians working with the crisis team at the two clinics. Secondary consultation is available from the on-call psychiatric registrar, consultant psychiatrist or from another clinician within the crisis team.
All contacts (either face-to-face or by telephone) with either the mental health clinic or the triage worker are recorded in a standard form on an electronic Word document. Each weekday morning a review meeting is held to discuss all contacts from the previous day. Most clinicians within the clinic including duty workers, team managers and medical staff attend the meeting. Each contact is discussed and further issues for follow-up identified.
Methods
The study used a programme evaluation approach and included a range of both quantitative and qualitative data.
Document analysis
Documents that related to the duty/triage system were reviewed. Information on services and the organization of duty/triage systems was identified from internal documents describing the system and from informal discussions with staff. The first author was employed at the mental health service during the period of the research.
Content analysis of duty/triage data
1. Quantitative analysis of routinely collected data July, August and September 2000
All patient related contacts with the duty/triage worker during July, August and September 2000 were collated and analysed. Each contact was recorded in a standard electronic format that included date, time, site, patient details, referrer, nature of inquiry and outcome. These data were converted to an Excel format and coded by the first author.
2. In depth analysis of data over one week period August 21–27, 2000
One week of data, from the three month sample was subjected to a more detailed analysis. The week chosen was a convenience sample, to represent a typical week. The week contained no public holidays and was outside school holiday periods.
The data for this week were compared with the full sample. Generally, the typical week was consistent with the three-month sample although more contacts recorded in the typical week had missing information on the time of the contact (p < 0.001) and there was a higher proportion of people contacting for clinical advice as the reason for referral (p < 0.05).
A detailed qualitative analysis of the data from the typical week was conducted. All contacts for new patients who were living in the catchment area that were referred during the week were reviewed and divided into three categories, assessment, no assessment and assessment not applicable. Themes were developed using the immersion/ crystallization (I/C) method. Immersion/crystallization consists of a series of cycles whereby the researcher is immersed in the text. Reportable interpretations are reached through reflection and intuitive interpretation. Immersion/crystallization can be both content and theory driven [6]. For instance, risk assessment emerged as an important theme from the literature and the data were explored to identify how risk was characterized. In contrast, the multiple references to other treating professionals in the data led to the development of ‘existing treatment team’ as a theme.
Key informant interviews
Key informant interviews were conducted to provide an overall view of the role and function of duty/triage from the perspectives of key stakeholders. A key informant from the State Government, general practitioners, consumers and carers were interviewed using a semistructured interview schedule. The consumer and carer informants were identified by approaching peak organizations. All interviews were confidential and were audiotaped and transcribed.
Results
Summary of data
Two thousand, six hundred and three patient related contacts for the three-month period were analysed. Table 1 summarizes the contacts according to site, whether the identified patient was a current patient of the AMHS, whether the person was referred for assessment in the mental health service, and outcome of the contact.
Over 60% of patient contacts occurred at the Emergency Department outside usual business hours. There were almost equal proportions of current and new patients referred to the service. New patients were people not currently receiving treatment in the AMHS, although they may have received treatment in the past. Less than 25% of patients were referred by duty/triage for comprehensive assessment by the clinic, CAT or psychiatric registrar. The most common outcome was providing support or information, followed by referral to the clinic and referral to CAT.
Contacts with the mental health service duty/triage system by site, current patient status, assessment and outcome
Source of referral
Half the patients either referred themselves (38%) or were referred by a carer (16%), with the Emergency Department and other mental health services each referring 11% of patients. General practitioners referred 3% of patients. Not surprisingly, current patients initiated over half of their contacts themselves (58%). For new patients, the commonest source of referral was carers (20%) followed by self-referral (19%), the Emergency Department (18%), and other mental health services (16%). General practitioners referred 4% of new patients to the duty/ triage worker.
Referral source differed according to whether the referral occurred in or outside usual business hours. During business hours the most frequent sources of referral were carers (22%), other mental health services (21%), community agencies (21%) and self-referrals (16%). Outside business hours the most frequent sources of referral were the emergency department (33%), self (21%), carers (18%) and other mental health services (12%).
The duty/triage data for the sample week were reviewed to identify any documented pathway from a general practitioner (GP) when the GP was not the direct source of referral. The duty/triage data indicated that people learn about the system either from previous experience, the experience of other friends or family or from contacting other mental health services. There was no reference in the data to patients being told about the service by a GP.
Referred for assessment
Overall, 456 (37%) new patients were referred for assessment, 180 (23%) contacted the mental health service for reasons other than to obtain an assessment (for instance seeking general information about mental illness, or requesting help for a person who lived outside the catchment area) and 576 (40%) were not referred for assessment following contact with the duty/triage worker.
New patients referred by GPs (60%) were the most likely to be assessed. People referred by private psychiatrists and by the emergency department were assessed in 52% and 48% of cases, respectively. Those referred by carers (32%) and self-referrals (33%) were the least likely to be assessed.
Sample week analysis
During the sample week 60 contacts for new patients who lived in the service catchment area were reviewed. Twenty-three contacts had been referred for assessment and 37 had not.
Description of mental state
The notes on 27 of the contacts, 14 (61%) assessed patients and 13 (35%) not assessed patients provided some description of the person's mental state, although in most cases the description was brief. Descriptions of mental states for patients who were assessed, generally characterized the mental state in technical terms, most commonly describing psychosis.
There were fewer references to mental state among ‘not assessed’ patients, and those references tended to be brief, vague or expressed the problem in non-technical language. Terms such as ‘counselling’, ‘sad and depressed’, and ‘anger issues’ were used to characterize either the person's mental state or the assistance they required.
Risk assessment
There was minimal documentation of risk for either ‘assessed’ or ‘not assessed’ patients. Where risk was documented it was vague and appeared at the end of the entry suggesting that it was the rationale for the course of action. More frequently risk was mentioned obliquely in the context of suicide or aggression.
History of mental illness
Half (19) the ‘not assessed’ patients had a reference to the person having a history of a mental illness. The most frequently mentioned past psychiatric history was a history of treatment for psychosis including schizophrenia (5), followed by depression (3), bipolar disorder (3) and personality disorder (2).
The consumer informant suggested that diagnosis was important in accessing a mental health assessment. Disorders such as schizophrenia and bipolar disorder were seen as much more likely to result in an assessment than borderline personality disorder or anxiety disorders.
Drug and alcohol use
Twelve of the ‘not assessed’ patient contacts mentioned a drug or alcohol problem while there were only four such references among the ‘assessed’ patients. Key informants indicated that mental health assessments were more difficult to obtain if the person had a history of drug or alcohol abuse.
Length of time between referral and assessment
For the sample week, all new patients referred for assessment were divided into two categories. The first category were new patients who had an assessment within 24 h, the second included people assessed more than 24 h after contact.
Almost half the new patients assessed (12) had an assessment within 24 h. There were few similarities among this group, although in most cases the referrer had either requested the urgent assessment, or the patient had presented to the emergency department.
Thirteen of the new patients assessed waited longer than 24 h for assessment, with the length of time between one and 11 days. Many of these patients were either transferred from another mental health service, or the referring person stated that the referral was ‘not urgent’. However, in some cases the reason for delay was unclear, particularly when there appeared to be some risk to the person.
Outcome
The commonest outcome for both current (50%) and new patients (34%) was providing support and information: including advice on access to psychiatric crisis services, advice to contact a general practitioner or private psychiatrist, and advice about access to private psychiatrists (including those who do not require payment beyond the compulsory insured levels) or other support services. Other outcomes included referral to the clinic (20%), crisis team (15%) or psychiatric registrar (2%) for further assessment.
Discussion
Duty/triage is a complex program. It is provided across several sites in the mental health service and involves a large number of clinicians. Documentation of the presenting issues and the rationale for decision-making is limited.
The role of duty/triage in the treatment of existing patients within the mental health service is important. while the focus of this paper is persons who are not currently being treated by the mental health service, there are nevertheless important policy and research issues associated with duty/triage systems for existing patients. Which patients use the duty/triage system and what impact does it have on their care? How is continuity of treatment ensured across different service sites, times and workers? What communication strategies are used and how effective are these? These are just a few of the issues that require further investigation.
Few patients were referred to duty/triage from primary health care (general practice), with most either referring themselves or referred by a carer. This suggests that the GP is not actively involved in the referral process for the vast majority of new referrals to the mental health service. Given that GPs treat the majority of people with a mental illness, the finding that they are not a central part of the pathway to specialist treatment raises clinical and policy concerns. Further investigation is required to identify whether this is an anomaly within one mental health service, or whether this is the situation in other mental health services within Australia.
This study illustrates the role that duty/triage plays in allocating resources. Less than half the new patients who contacted the mental health service were referred on for further assessment. This does not imply that the decisions were inappropriate, nor that everyone who contacts duty/triage should be assessed. Rather it illustrates an internal pathway within mental health services that acts as a filter and mediates access to a mental health assessment. Further research could usefully focus on the rationale and processes determining such decisions.
A consistent and well-supported entry system for mental health services is an important part of reducing the variance in clinical decision-making [4]. This study suggests that at the entry point to a mental health service, limited information about the presenting problem and risk is collected at entry. While there is some informal agreement on how to respond to specific clinical situations, there is also considerable variation in the information about decisions documented by duty/triage clinicians, and limited opportunity for consultation in the decisionmaking.
While the study is limited by the reliance on routinely collected data and the brevity of the documentation, the recording of all contacts with duty/triage with little missing data in a standardized electronic format enabled the analysis of previously collected data.
Conclusion
A substantial number of patients contact the mental health service every day. Most contacts do not result in further assessment in the service. This study identified that there is little interaction with primary health care at entry to the specialist system, limited documentation of risk and a lack of consistency in the documented reasons for the mental health services’ response to a person with a mental health problem. While these results cannot necessarily be generalized to other mental health services, they do illustrate the important role of entry systems to mental health services and the need to have consistent, quality clinical decision-making processes.