B.29[17h] Mental health: Efectiveness of the planning to discharge people from hospital Ofce of the Auditor-General PO Box 3928, Wellington 6140 Telephone: (04) 917 1500 Facsimile: (04) 917 1549 Email: About our publications All available on our website The Auditor-General’s reports are available in HTML and PDF format on our website – www.oag.govt.nz. We also group reports (for example, by sector, by topic, and by year) to make it easier for you to fnd content of interest to you. Our staf are also blogging about our work – see blog.oag.govt.nz. Notifcation of new reports We ofer facilities on our website for people to be notifed when new reports and public statements are added to the website. The home page has links to our RSS feed, Twitter account, Facebook page, and email subscribers service. Sustainable publishing The Ofce of the Auditor-General has a policy of sustainable publishing practices. This report is printed on environmentally responsible paper stocks manufactured under the environmental management system standard AS/NZS ISO 14001:2004 using Elemental Chlorine Free (ECF) pulp sourced from sustainable well-managed forests. Processes for manufacture include use of vegetable-based inks and water-based sealants, with disposal and/or recycling of waste materials according to best business practices. Photo acknowledgement: © Naruedom Yaempongsa/Shutterstock.com B.29[17h] Mental health: Efectiveness of the planning to discharge people from hospital Presented to the House of Representatives under section 20 of the Public Audit Act 2001. May 2017 ISBN 978-0-478-44266-3 Contents Overview 3 Our recommendations 6 Part 1 – Introduction 7 The purpose of our audit 7 What we audited 9 What we did not audit 9 How we carried out our audit 9 The structure of this report 12 Part 2 – Acute mental health care 13 Organisations with a role in providing mental health care 13 Patterns of contact with mental health services 14 Mental health funding 16 Part 3 – Planning for discharge from an inpatient unit 17 Discharge planning is adversely afected by high demand 18 Discharge planning often fails to cover broader needs 19 There is scope for better collaboration in discharge planning 20 Systems and tools do not support efective and efcient discharge planning 22 Part 4 – Supporting people after they leave an inpatient unit 25 Follow-up rates are well below expectations 25 Barriers make it hard for people to get support after being discharged 26 Part 5 – Using information to assess outcomes 28 Using data about mental health services to report on and understand service performance 29 Eforts to improve how information is used 32 Using information better to improve services and understanding 35 Appendix – Letter from the Ministry of Health 41 Figures 1 – Proportion of New Zealanders who experience mental health problems and access specialist mental health services 8 2 – Percentage of bed nights for the cohort as a proportion of all mental health bed nights in all district health boards 10 3 – Percentage of community contact activities for the cohort as a proportion of all mental health community contact activities 11 4 – Number of beds in inpatient units for every 100,000 of population, by district health board 15 5 – Inpatient unit occupancy rate per day for a DHB with a high level of bed pressure, year ended 30 June 2015 19 6 – Summary of district health boards’ results against six key performance indicators, 2012/13-2014/15 31 7 – Profle of when re-admissions occurred for re-admissions between 1 and 28 days after discharge, 2011/12-2014/15 36 8 – Distribution of re-admissions and all inpatient unit stays for people at fve small district health boards 38 2 Overview He aha te mea nui o te ao? He tāngata, he tāngata, he tāngata. Mental health problems afect New Zealanders from all walks of life, with one in fve people afected each year. Many people with serious mental illnesses also sufer chronic physical health conditions and many live shorter lives. Mental illnesses can also impact families, friends and care-givers, and communities. The personal, societal, and economic costs are high. In November 2016, the Ministry of Health’s Director of Mental Health reported that specialist mental health and addiction services are experiencing increasing pressure. Numbers have been increasing every year since at least 2003. In 2015, a record number of people, more than 160,000 or 3.5% of the population, used these services. Of these, about 15,000 people needed to stay in an inpatient unit during 2015. District health boards spent more than $200 million providing care to mental health patients in hospitals. People who are admitted to a hospital-based inpatient unit for mental health problems are in greatest need of support. Supporting them is difcult and demanding, especially for those directly involved in delivering services, and requires the co-ordination of a wide range of health and broader social services. If the system fails in efectively supporting these people, there are huge implications for them, their families, and the health and other sectors. Getting it right is an investment with signifcant payback. International evidence shows that good planning before a person is discharged from hospital to community support services is critical in efectively supporting people with mental health problems. When done well, “discharge planning” brings together a person’s health and broader social needs and enables those needs to be met. This report considers whether discharge planning is completed as intended, whether the needs identifed are met after people leave hospital, and whether discharge planning is helping to improve outcomes for people. My staf analysed data for all district health boards, closely inspected practices at three district health boards, and considered the views of a broad range of people directly involved in delivering services. We focused on people experiencing mental health problems acute enough that they were admitted to hospital. Although they are a relatively small group, their acute and often complex health problems mean that they can need a large amount of care and support from the country’s health services. 3 Overview Overall, the timeliness, quality, and efectiveness of discharge planning (and the associated follow-up work) are impaired by pressures on inpatient and community services and other factors. The extent of these pressures and how well discharge planning is done varies. Some inpatient units have high occupancy rates – sometimes beyond their capacity – and in some places there is limited availability of community services, such as suitable accommodation, to discharge people to. In these circumstances, discharge planning can be late or incomplete, and may not involve everyone who needs to be included for it to be efective. This means that people with mental health problems can be discharged from hospital without a plan for their broader needs, such as getting help with housing, their fnances, or support from their employer or family. In my view, improvements are urgently needed for discharge planning to be more efective in enabling better outcomes for people with mental health problems. The pressures on inpatient units and community services need to be addressed. Most district health boards use a collaborative approach to discharge planning – they seek to involve the inpatient unit and community mental health teams, the person with the mental health problems, and that person’s family. However, the extent to which diferent teams, the individual concerned, and their family are involved is variable and sometimes limited. Follow-up with people after they had been discharged was also not as timely as expected. Nationally, district health boards follow up with only two-thirds of people within seven days. Their target is to follow up within seven days with at least 90% of people discharged after staying in hospital because of acute mental health problems. There are also barriers to discharge plans being implemented. People, especially those with complex needs, do not always have access to the services they require, including services outside the control of the health sector. The mental health sector has made progress in recent years in using information to understand service performance and how to make improvements. However, there is more for the Ministry of Health and district health boards to do to make better use of information to understand what infuences outcomes for people, including the efectiveness of discharge planning, and make service improvements. For example, more work is needed to systematically gather and use feedback from people using mental health services and those supporting them. The mental health sector has started to take a more people-centred view in how it uses information to understand how well services are delivered. In my view, 4 Overview it can do more. My staf have been sharing the insights they gained from using the Ministry’s data to map when and how people have been in contact with a range of acute mental health and other health care services. We took the concept, developed by people working in the health sector, and refned it to highlight its potential uses, which we have shared with people in the sector. During the audit, my staf met with many people who are doing the best they can to provide the best mental health support services they can, despite obstacles and hurdles. These people are well aware that the consequences for people with acute mental health problems, their family, communities, and other agencies can be signifcant if discharge planning is not done well or discharge plans are not acted on. The increasing demand for acute mental health services and the problems with co-ordinated support in the community are not new. In my view, the Ministry and district health boards need to urgently make demonstrable improvements to deliver better results for people with acute mental health problems. Since we completed our feldwork, the Ministry and district health boards have been working on changes to improve mental health service delivery, including to better support people in moving from inpatient units to community mental health services. The efectiveness of these changes is yet to be determined. On this occasion, I have decided to include, as an Appendix to my report, a letter from the Ministry of Health that outlines these changes. This is to provide an update and a reference point to help Parliament and the public hold the Ministry and district health boards accountable for delivering better results for people with acute mental health problems. I thank the many people in the mental health sector who shared their views, information, and expertise with my staf as they carried out their work. Nāku noa, nā Greg Schollum Deputy Controller and Auditor-General 25 May 2017 5 Our recommendations There are clearly pressures on parts of the mental health system and support services that demand urgent attention and, potentially, innovative solutions. In this challenging context, the planning for discharging people dealing with acute mental health problems from hospital needs to be done to a high standard. We recommend that district health boards: 1. urgently fnd ways for inpatient and community mental health teams to work together more efectively to prepare and implement discharge plans, ensuring that all those who need to be – the person to be discharged, family, other carers, and all service providers – are appropriately involved and informed; 2. help staf by improving the guidance and tools to support discharge planning (including information systems) so that the information needed for discharge planning can be accessed and brought together easily and efciently; and 3. regularly review the standard of discharge planning and follow-up work to identify and make improvements. We recommend that the Ministry of Health and district health boards: 4. quickly make improvements to how they use information to monitor and report on outcomes for people using mental health services; and 5. use the information from this monitoring to identify and make service improvements. 6 Introduction 1 1.1 In this Part, we discuss: • the purpose of our audit; • what we audited; • what we did not audit; • how we carried out our audit; and • the structure of this report. The purpose of our audit 1.2 Mental health problems afect New Zealanders from all walks of life, with one in fve people afected each year. The number of people accessing specialist mental health services has been increasing steadily since at least 2003. 1.3 We carried out a performance audit that focused on the relatively few people who are most unwell with mental health problems and require a high level of care, including care in a hospital-based inpatient unit. We looked at whether: • planning for these people’s discharge from an inpatient unit to community care was completed as intended; • the needs identifed by discharge planning were followed up after discharge; and • discharge planning was helping to improve outcomes for people with acute mental health problems. 1.4 Figure 1 shows the proportion of the total population that experience mental health problems and that access services at diferent levels. Most people receive mental health care services in primary health care settings, usually with their general practitioner (GP). However, more than 160,000 New Zealanders (3.5% of the population) accessed specialist mental health and addiction services in 2015. About 15,000 (9%) of these people were admitted to an inpatient unit. These 15,000 people required a high level of care. When they were admitted, many were considered to pose a serious danger to themselves or others as a result of their mental illness. Some of them were admitted under a compulsory treatment order. 1.5 Providing inpatient care is expensive. District health boards (DHBs) spend a signifcant amount of their specialist mental health funding on inpatient units. Sometimes DHBs ofer alternatives to inpatient treatment that support people to stay in the community. These can help to reduce the pressure on inpatient units. 1.6 It is important that people receive good planning and appropriate follow-up for their discharge from hospital care and transition back to the community. International evidence shows that good planning for the transition from inpatient units to the community is critical in efectively supporting people with mental health problems. 7 Part 1 Introduction Figure 1 Proportion of New Zealanders who experience mental health problems and access specialist mental health services Annually, of every 1000 people in NZ: 200 will experience a mental health problem. 35 of those people will receive specialised treatment… … and 3 will be admitted to an inpatient unit. Source: Our analysis of available data. 8