GUIDELINE SESLHDGL/022. Low N/A. Acute patient flow Sustainable access Community engagement Emergency Bed Management

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1 MENTAL HEALTH SERVICE GUIDELINES NAME OF DOCUMENT TYPE OF DOCUMENT DOCUMENT NUMBER Acute Patient Flow and Sustainable Access Management for Mental Health GUIDELINE SESLHDGL/022 DATE OF PUBLICATION January 2013 RISK RATING LEVEL OF EVIDENCE Low N/A REVIEW DATE January 2018 FORMER REFERENCE(S) EXECUTIVE SPONSOR or EXECUTIVE CLINICAL SPONSOR AUTHOR KEY TERMS SUMMARY Revision and Approval History This replaces the former SESIAHS MH Acute Bed Management and Sustainable Access Guideline Dr Murray Wright, Director SESLHD MHS Gayle Jones SESLHD MHS Acting Access & Service Integration Manager Acute patient flow Sustainable access Community engagement Emergency Bed Management This Guideline was developed to serve as a benchmark to maximize the efficient use of acute mental health beds and to ensure improvement and consistency in the management of patient flow across the mental health service. Date Revision Number Author and Approval 22/11/ Gayle Jones SESLHD MHS Acting Access & Service Integration Manager, replaces previous SESIAHS Guideline Revision no. 0 Document No. T13/4338 Date: January 2013 Page 1 of 20

2 MHS GUIDELINES POLICY GUIDLES Acute Patient Flow & Sustainable Access Management Updated November 2012 Content 1 Forward 2 Executive Summary 3 Introduction 4 Purpose 5 Scope 6 Policy Development 7 Overarching Principles 8 Responsibilities 9 Assessment & Decision to Admit 10 Acute Bed Management 11 After Hours Bed Management 12 Self Sufficiency & Demand Plan 13 Community Engagement 14 Medical Superintendent s Role 15 Leave Beds 16 NSW Patient Flow Portal 17 Homeless Patients 18 Emergency Bed Management 19 Over census 20 Reserving Local Beds 21 Transfers 22 Use of Medical /Surgical Beds 23 Repatriation Plans 24 Non SESLHD MHS Bed Requests 25 Special Flow Circumstances 26 Disagreements 27 Police Beds 28 Appendix Forward Sustainable access to the Mental Health Service is one of the key health priorities for South Eastern Sydney Local Hospital District Mental Health Service (SESLHD MHS). The Acute Patient Flow & sustainable Access Management Guideline aims to facilitate a planned, non-reactive predicted bed model to synchronize and sustain patient flow within the Mental Health Service across the District. The broad ranging scope and strategic vision of this Guideline reflects the commitment that demand management within Mental Health Services extends across the life span and can only be provided in partnership with consumers / carers, general practitioners, specialist government services and non government service providers. The continued challenges of continued access and synchronized flow are considerable. The Patient Flow Team will endeavour to build on patient flow achievements of proven value and incorporate a results based accountability framework for future development to ensure that the SESLHD MHS program moves towards providing optimal and sustainable access. Executive Summary All persons requiring Mental Health Services deserve timely and efficient access to the best possible care. Patient flow to acute and non-acute care facilities should be viewed within a continuum of care in which the complimentary inpatient and ambulatory care settings collaborate to assertively promote rehabilitation and recovery for people with a mental illness. This guideline emphasises synergy with the coordination of different, yet connected teams and services, in order to be flexible in providing high quality patient care and services in the most appropriate environment for the person. It is paramount that this sustainable access model responds not only to expressed demand but also to unmet needs. Articulating a transparent and cohesive approach to SESLHD MHS flow, this guideline serves to maximize self-sufficiency and cooperation between service units. Revision no. 0 Document No. T13/4338 Date: January 2013 Page 2 of 20

3 Introduction Local bed management Procedures must include demand plans with pre-emptive strategies for critical periods such as weekend s public holidays & special event planning. The guideline replaces the South East Sydney and Illawarra Area Mental Health Acute Bed Management Policy (2003) and the South East Health Area Mental Health Acute Bed Management Policy (2008). It has been developed to ensure consistency and equity of access across the District services. It is designed to operationalise patient flow as distinct from decision to admit or not admit. Operationally it is to be used in conjunction with the NSW Patient Flow Portal and individual unit- based bed management/ patient flow policies and procedures. Each Service site within the District providing mental health services is responsible, in consultation with consumers and carers, for drafting, maintaining and reviewing local patient flow policies and procedures. These policies and procedures guide clinical and process decision-making. Local bed management policies and patient flow practices must include a demand plan with strategies for managing periods of increasing occupancy, especially during critical periods such as weekends, public holidays and special event planning. Purpose This guideline has been developed to serve as a benchmark to maximize the efficient use of acute mental health beds and to ensure improvement and consistency in the management of patient flow across the mental health service. Improving flow between networked Mental Health Services The g u i d e l i n e also aims to ensure priority for the management of mental health clients in the Emergency Department setting, including timely decision making and discharge or transfer to a more appropriate setting. The key principles underpinning the Policy are: District self sufficiency in managing acute Mental Health bed demand. Engaging senior clinicians in ongoing review of their bed management and related clinical practices, including: bed usage, discharge planning, quality improvement and continual evaluation of programs and treatments. Improved flow of mental health inpatients from acute units to medium and long-term care facilities and other alternate care. Improved patient flow and co-ordination between Emergency Departments, Acute Mental Health Services and Community Mental Health Services. Planned, non reactive predicted bed model to synchronize and sustain patient flow within SESLHD MHS Improving flow between the LHD s Mental Health Services. Scope This guideline applies to all SESLHD MH S e r v i c e s providing acute Inpatient mental health care. The guideline includes Psychiatric Emergency Care Centres (PECC) and specialist older persons units within SESLHD MHS and plans to include Mental Health Intensive Care services. Page 2 Revision no. 0 Document No. T13/4338 Date: January 2013 Page 3 of 20

4 Guideline Development There are a number of principles, legislation, Memoranda of Understanding and standards informing this guideline. These include: Principles for Acute Mental Health Bed Management: Centre for Mental Health, NSW Health Department (2005). Work Health & Safety principles: safe working environment, limiting agitation and aggression Work Health & Safety legislation: safe working environment for all staff Mental Health Act 2007(NSW): the best possible care and treatment for clients in the least restrictive environment, any interference with or restriction of client s rights, dignity and self-respect is to be kept to the minimum required to ensue patient safety, safety of others and access to appropriate treatment. National Standards for Mental Health Services: equitable access to appropriate mental health services when and where they are needed; organizational structures and routine dialogue between service programs to ensure continuity of care and systems for prioritizing risk and clinical need (see Standards: 2.3, 8.1.3, 9.4, and 11.4.E.1) Onus is on each service to support sustainable access across the District whilst promoting self management and self sufficiency Homelessness: It s Everyone s Business: a mental health response by South Eastern Sydney and Central Sydney Area Health Services Memorandum of Understanding document (July 2002) Memorandum of Understanding between NSW Police and NSW Health (October 2006) Admission of Mental Health Patients to Medical (General) Beds Policy (February 2009) SESLHD MHS Patient Flow Operational Tool (December 2010) Patient Leave from Acute Inpatient unit policy(april 2012) Intra-Hospital transfer of Mental Health Inpatients. Business Rule(March 2010) Repatriation of Patients from Mental Health Intensive Care Units. Business Rule.(November 2011) Referral to Mental Health Intensive Care Units. Business Rule.(April 2010) SESLHS MHS Extraordinary Event Management & Demand plan for acute inpatient beds PECC patients greater that 48hrs in PECC. Business Rule. (August 2011) On-Call responsibilities for s & Consultants in Psychiatry. Area Mental Health program.(april 2010) Complex Case Conference outline for recurrent crisis presentations or admissions. Business rule. (January 2012) Communication/escalation process related to patients in Emergency Department awaiting MH admission. Business Rule. (March 2012) Revision no. 0 Document No. T13/4338 Date: January 2013 Page 4 of 20

5 Page 3 Overarching Principles All Mental Health Service Sites and SESLHD MHS have agreed to the following overarching principles for this guideline. Onus is on each service to support sustainable access and self-sufficiency across the SESLHD whilst promoting selfmanagement and service site self-sufficiency. All other alternatives to hospitalisation that are deemed appropriate to the client s clinical need and circumstances should be explored whenever possible. Acute mental health treatment is most effective when well integrated with community mental health services, family and social networks and other community supports. Where acute admission is indicated, treatment in an acute mental health inpatient unit close to a person s usual residence is preferable. Irrespective of the client s address, a service to which a person has presented has the responsibility for ensuring appropriate care in the first instance. Boundaries between services should not be rigidly applied at the expense of good clinical care. All services sites accept the need for pre emptive strategies and co-operation in managing peaks of demand, and for respectful and professional interactions between staff. On-call Psychiatry s should not take the operational role of after-hours patient flow manager or be primarily involved in bed finding and or/ negotiation between services regarding bed availability. However the On call Psychiatry s, together with the Duty Consultants, have explicit responsibilities in clinical bed management and clinical transfers between services. All service sites accept the need to engage senior clinicians in ongoing review of their patient flow management and related clinical practices, including; bed usage, discharge planning, planning for transfer of care, quality improvement and continual evaluation of programs and treatments. Revision no. 0 Document No. T13/4338 Date: January 2013 Page 5 of 20

6 Responsibilities Mental Health service sites are responsible for: Drafting, maintaining and reviewing local patient flow policies and procedures in consultation with consumers and carers For guiding clinical and process decision making to reflect up to date, evidence based, clinical and service delivery consistent with the SESLHD Mental Health Acute Bed Management Policy Benchmarking quality data against other services to ensure quality in clinical decision making and maximal efficiency and effectiveness in resource utilisation Ongoing refinement of effective systems for community based care Continuing to work to reduce inappropriate longer lengths of stay, unplanned readmissions and delays in discharge Providing SESLHD MHS with the information required to effectively advocate for increased resources within Mental Health Service and improved access to other forms of care SESLHD Mental Health Service is responsible for: Providing a framework for coordination and management of SESLHD MHS resources and services Promoting cooperation within the LHD and with other health services Promoting a development of systems across the LHD that is compatible with and supportive of, the development of the Mental Health Sectors Developing and maintaining partnerships between SESLHD MHS, local service sites and external agencies Monitoring and reporting of service site and LHD performance in regard to acute bed utilisation and efficiency Strategic planning for LHD mental health bed needs across the spectrum of bed requirements and advocating for the resources required to meet the needs identified. Assessment and Decision to Admit All Mental Health Units are to have guidelines that emphasise the importance of comprehensive assessment, consideration of the full spectrum of available treatment options and settings that include an understanding of local systems, roles of mental health and community teams and consultation processes with Liaison Psychiatry and the Emergency Department Assessment should be comprehensive (MHOAT documentation) and must include medical problems and acute and potential level of risk and disability. Admission should only occur when community care is not appropriate after consultation with relevant community mental health services and with authorisation of the Medical Superintendent, or delegate. The decision to admit must be authorised by the Medical Superintendent or delegate. All assessments and decisions regarding admissions must be documented and admission documentation should set clear goals for admission. These goals should be developed with the client and carers where ever possible. Clinical need and consideration of available treatment options should inform the decision to admit. The decision to admit should not be predicated on the availability of inpatient beds. Revision no. 0 Document No. T13/4338 Date: January 2013 Page 6 of 20

7 SESLHD MH Bed Management Team SESLHD Acute Mental Health Bed Management Business Hours Access Bed request SESLHD The SESLHD MH Bed Management Team comprises of the District MH Access & Service Integration Manager and the two sector based Patient Flow Coordinators. This team works across the mental health clinical program to ensure timely communication, active problem solving and rapid operational response to issues. An escalation process has been established that includes local site Mental Health Service Directors and the District Director of Mental Health as required to assist in the management of access blocks. Local Patient Flow Coordinator (PFC) Local Site Based Patient Flow Coordinators (PFC) STG/TSH PFC Situational Management POW PFC LHD MHS Access & Service Integration Manager Situational Management Director of Operations SESLHD MHS Director SESLHD MHS Sector Service Director To ensure patients receive timely access to appropriate care a n d move safely and efficiently through the system without unnecessary delay Local Site Based Patient Flow Coordinators Responsibilities To sequence, track, and reroute any aspect of patient flow to optimise resource and time management to: - Orchestrate the operational processes of admissions and discharges using ED/EAP/ Activity KPI Data Foster local site-based zero tolerance philosophy for barriers to flow Contact Details St George & Sutherland Hospitals & Health Services Patient Flow Coordinator (Bus. hrs) Ph: Prince of Wales Hospital Patient Flow Coordinator (Bus. hrs.) Ph: SESLHD MHS Access & Service Integration Manager (Bus hrs) Ph: Ph: After Hours Bed Management The Nurse In Charge of each respective Mental Health Acute Inpatient Unit is responsible for site-specific after-hours operational patient flow. On-call Psychiatry s should liaise with the respective On -call Psychiatric if bed is required at another venue within the SESLHD. Should escalation be required to secure a bed within SESLHD, the Consultant on-call, then Site Service MH On-call Executive may be required to become involved. Escalation to the SESLHD MH Director should be a rarity. Mobilise internal resources on complex cases that require a multidisciplinary approach to discharge planning Provide c o m p r e h e n s i v e, transparent a n d t i m e l y information to all stakeholders Decrease variability a n d s yn c h r o ni z e local and SESLHD patient flow Sustain p r o f e s s i o n a l r elationships among multiple hospital staff and units. Monitor and reconcile data entered into the NSW Bed Board against data gathered from other sources (e.g. IPM/PAS, verbal communication with managers). Assist in local site-based process for continuously reviewing patients with above average lengths of stay. Create a local site-based system of planned flow and planned discharges. Revision no. 0 Document No. T13/4338 Date: January 2013 Page 7 of 20

8 SESLHD MHS Extraordinary Event Management and Demand Plan for Acute Inpatient Beds Level Threshold Demand 0 Proactive Routine Practice Indicator Facility Mental Health Beds Available Facility Emergency Department Beds Available. Nil issue with Mental Health Inpatient Bed Access Predicted Discharges match predicted Emergency & Planned admissions Authority to invoke resource mobilising capacity Site Senior Nursing Manager/Operations Manager and Site Service Directors Actions Transport and Escort Duties Resource list of medical, nursing and support staff available for overtime/and or transport/escort duties. Resource bases to include community MH, MH Consultation Liaison, Nursing Allocations Office and other SESLHD MHS workforce. Workforce Planning with Nursing Agencies to secure sufficient numbers of agency personnel with appropriate skills sets Identified sub acute patients suitable for transfer to adjacent network services using non police/ambulance transport Community Team Presentations Standardise a Triage Assessment Process where all Community Referrals to the SESLHD MHS are triaged via the CMT Leader and individually discussed with the Patient Flow Coordinator in consultation with the Duty Consultant. Demand Capacity Predictive Bed Model and capacity planning with identified inpatient discharges, planned leave and contingency leave for each day Identify OOA Clients and commence repatriation planning Identify Private patients and commence private facility negotiations Suitable ECT procedures to be mobilised to Day Only Mobilise Non Acute Referrals/LLOS Meeting and Second Opinion Processes/Assertive Care Progression Model of Care Emergency Department Key MH/ED CNC KPIs around completion of MHOAT Assessment Module with purposeful admission plan/projected LOS, bed finding negotiations Assertive planning around comprehensive ED discharge planning including standard community information pack/aods/sexual Assault/ support agency information/ pre packs of medications / pharmacy dispensing medications after hour s information/ngo support services Emergency Department escalation plan for managing multiple presentations, co morbid AODS/Clinical Pharmacology/Sexual Assault cases/non English Speaking presentations or surges in MH emergency assessments to be formalised and circulated to all operational teams 1 Patients requiring Mental Health inpatient admission and no local mental health beds available No Facility Mental Health Beds Available < 2 Facility Emergency Department Beds Available. Predicted Discharges less than predicted Emergency & Planned admissions Site Senior Nursing Manager/Operations Manager and Site Service Directors in Consultation with District Mental Health Access Manager and Local Patient Flow Coordinator, Staff Specialist or Transport and Escort Duties Circulate standardised briefings to SVH Transport, SESLHD Community Transport Drivers and NSW Ambulance to increase staff awareness/preparedness and support for increased service demands. Community Team Presentations Standardise a Triage Assessment Process where all Community MH Referrals to the individual sites are triaged directly by the sites/the sites CMT Leader and individually discussed with the Nursing Manager/Operations Manager Revision no. 0 Document No. T13/4338 Date: January 2013 Page 8 of 20

9 1 2 All SESLHD Mental Health Beds full + > 8 hrs unplaced mental health patients in a SESLHD Emergency Department. Facility ED full and unable to off load ambulances > 5 MH patients waiting to be seen or waiting for MH review > 3 admitted MH patients awaiting transfer to MH Bed or Delay in discharges from Ward > 4 hours Site Senior Nursing Manager/Operations Manager and Site Service Directors in Consultation with District Mental Health Access Manager and Local Patient Flow Coordinator, Staff Specialist or, District Director Mental Health Demand Capacity Brief local Private Mental Health Facility Operations Mx to increase staff awareness/preparedness and support for increased service demands. Mobilize suitable current inpatients that have private MH insurance. Identified sub acute patients suitable for transfer to adjacent network services using non police/ambulance transport Negotiate and activate permanent or temporary transfers of non-acute patients to relevant MHRU Review Numbers of Leave Clients and redirect daily reviews to assertive Out Patient Review Clinics/Community Care Review patients on leave for potential to remain on extended leave Audit PECC admission plans and purpose of admission to ensure compliance with PECC admission classification within the NSW Health guidelines for PECC(<48hrs admission)emergency Department Negotiate redeployment of additional MH assessment resources from C/L Team/Rehabilitation/Outpatients to attend ED to manage increased load of presentations requiring assessment and management. Transport and Escort Duties Contingency planning around escort resources to be negotiated with Facility Corporate Services Manager who has governance over site employed community transport service drivers. Contingency planning around access to hospital vehicles for the purpose of non acute transport. Contingency Planning with NSW Non Acute Transport Services around extended access to non acute transport services. Circulate standardised briefings to NSW Police to increase staff awareness/preparedness and support for transport and potential service limitations. Community Team Presentations Restrict CMT admissions to psychiatric emergencies only. Patients will need to meet the requirements for involuntary admission under the MHA. CMT Admissions not meeting the above criteria should be negotiated directly with the Clinical Director/Service Director Community site demand and escalation plan for managing multiple referrals and increased service demand planning to be formalised. This to be circulated to all operational community teams. Demand Capacity ECT and/or elective outpatient appointments restricted to Psychiatric Emergencies Only Investigate clinically appropriate alternative accommodation options/hotels for all accommodation challenged patients who are occupying an acute MH bed inappropriately Situational escalation that may include deployment of MH skilled observation staff, patient transfer, occupation of regional or rural beds within NSW, occupation of local MH over census beds for limited & definitive periods, resource dependent Suspend all repatriation requests from other LHD to admit local client into an available bed within SESLHD MHS Admissions restricted to psychiatric emergencies in all SESLHD MHS services Patients will need to meet the requirements for involuntary admission under the MHA. Admissions not meeting the above criteria should be negotiated directly with the Clinical Director/Service Director Redirect or defer elective admissions, consider non acute network partner Bloomfield accommodation ( i.e. Clozapine trials) Suspend tertiary referral admissions to identified tertiary referral beds including NPI beds Mobilization of Medical Superintendant onsite to directly assist with review of inpatients suitable for leave OR discharge. Any PECC admission >48hrs to be endorsed by Clinical Director/Service Director. Emergency Department Invoke Emergency Department escalation plan for managing multiple presentations, co morbid AODS/Clinical Pharmacology/Sexual Assault cases/ Non English Speaking presentations or surges in MH emergency assessments including redeployment of C/L, Rehabilitation, Community medical resources and support teams Revision no. 0 Document No. T13/4338 Date: January 2013 Page 9 of 20

10 As above. Situational escalation process inclusive of District Mental Health Service Director. The repertoire of options may include specific risk mitigation strategies that may include the following actions for limited & Extraordinary definitive periods, resource dependant. Event Suspend all non SESLHD MHS admissions into available beds within SESLHD MHS + NSW Health. 3 as identified by the Chief Executive and District Director Mental Health Extraordinary Event Chief Executive and District Director Mental Health Circulate standardised briefings to other district health facilities to increase awareness/preparedness and support for increased service demands. Suspend SESLHD MHS MHRU Program and return MHRU patients to community. Co-manage Older Adult MH pts on General Hospital Aged Care Units/Behaviour Disturbed Units. Co-manage Older Adult MH pts in MAU/War Memorial Hospital/Garrawarra Hospital respite beds. Suspend all Justice Health Presentations/Schedule to SESLHD MHS. NSW Health to Circulate standardised briefings to Long Bay gaol to increase awareness/preparedness and support for transfer of pts to adjacent area. Reference: Lessons Learned from a Nightclub Fire: Institutional Disaster Preparedness. Journal of Trauma-Injury Infection & Critical Care. 58(3): , March Mahoney, Eric J. MD; Harrington, David T. MD; Biffl, Walter L. MD; Metzger, Jane RN, DNSc; Oka, Tomomi MD; Cioffi, William G. MD Mass Causality Management of a Large Scale Bioterrorist Event an Epidemiological Approach. Emergency Medicine Clinics of North America 2002 May;20(2): Revision no. 0 Document No. T13/4338 Date: January 2013 Page 10 of 20

11 Assertive Care Progression There should be at a minimum daily liaison (Monday-Friday) between the sector based Patient Flow Coordinator, Nursing Unit Manager (NUM) and Medical Superintendent (or delegates) regarding patient flow indicators, e.g. EDDs, available beds, predicted admissions. The relevant multi-disciplinary team in each MHU needs to confer at least twice per week to review each client s progress and EDD, and consider options such as discharge or leave. At each client s case review, an expected day of discharge is to be estimated (EDD). Community-based clinicians/case managers and MHU staff should assertively work towards achieving this discharge date. This EDD should be entered into the NSW patient flow portal by clerical staff. Each site is responsible for developing a framework for local site-based processes for assertively reviewing patients with above average lengths of stay to determine options in relation to alternative clinical management. The SESLHD MHS will utilise Section 49: Leave of Absence of the Mental Health Act 2007.Provision is made for the Medical Superintendent (or delegate) to allow a client to be placed on leave subject to certain conditions. Predicted Bed Model Each Service Site should aim to facilitate a planned, non-reactive predicted bed model over a 7-day period to synchronize and sustain patient flow. Assertive review of EDDs should occur routinely and weekend discharges should be planned before as early in the week as possible to establish the potential number of bed vacancies before the weekend or public holidays to allow for appropriate deployment of community resources. Proactive demand planning should occur each and every shift with consideration being given to ranking relevant clients in priority for discharge in preparation for any decisions regarding discharge that may need to made after hours, over the weekend or public holiday. Medical Superintendent Role From time to time, it is necessary to make decisions regarding discharge in the absence of the Consultant Psychiatrist under whom the client is admitted. The Consultant Psychiatrist (or delegate) is responsible for ensuring adequate notation is placed in relevant clients medical records in order for other staff members to make an informed decision regarding discharge. The notation in the medical record must include: levels of risk and changeability, community and social supports, level of community mental health services support and any other follow-up arrangements which are desirable to facilitate safe discharge. The final authority regarding discharge rests with the Medical Superintendent (or delegate). Leave Beds A leave bed is an "available leave bed" where an admitted patient is on prolonged leave (e.g. overnight or longer). Each MH Site should ensure a consistent approach to the use of available leave bed within SESLHD MHS. Where a MH Site has available leave beds, new patients should be generally be admitted to those beds in preference to seeking transfer to an inpatient unit in another District Health Service. Leave beds of clients who are expected to be discharged on return or are able to remain on leave, can be used for admission. All clients (and their carers) proceeding on leave should be made aware that their bed may be used. Clients need to be reassured that although they may not return to the exact bed they had before leave, staff will find them a bed upon returning from leave. Leave beds of clients who are certain to return before another bed can be found can be used as an absolute last resort. There should be planning and prioritizing with respect to these decisions with relevant clinicians. The use of the bed of a client who is absent without leave is a matter for the Medical Superintendent and NUM (or delegates) to decide on a case-by-case basis. Leave beds in SESLHD will only be considered for clients being referred from another Local Hospital District after consultation with and authorization by the Medical Superintendent (or delegate). Revision no. 0 Document No. T13/4338 Date: January 2013 Page 11 of 20

12 NSW Patient Flow Portal Bed Board The NSW Patient Flow Portal (PFP) Bed Board is the preferred strategic system for patient flow management for acute inpatient services The NSW PFP provides an overview of occupancy by ward for each hospital, health service or State wide view. Real time length of stay data is provided All sites should ensure mental health service participation in the use of the NSW PFP For full details on how to use the PFP Presence of an available bed on the NSW Patient Flow Portal Bed Board does not obligate a unit to accept a referral for admission All inpatient units must ensure data entered into the NSW PFP is current and updated as circumstances change. The NSW PFP should be used as a tool to identify potential available beds in other units with the SESLHD in conjunction with the usual processes of requesting a bed within the LHD The site PFC or delegate should contact the respective site PFC to discuss the potential to accept a suitable patient transfer Homeless Patients Irrespective of catchment or District of residence, a service to which a person has presented has the responsibility for ensuring appropriate care. In general, the presentation of a homeless person to a MHU must be viewed as an opportunity to re-appraise treatment goals and engagement with mental health services. This approach is often more flexible than with persons of known address or catchment area. The decision to admit or transfer to another MHU should be made on clear consideration of the best interests of the client, rather than rigid application of catchment principles or protocols. In general, homeless persons are to be considered the responsibility of the service where the person first presents. Consideration should be given to factors which are in the best interest of the client s treatment, for example, the site of most recent discharge, client s preference, availability of support networks, carers wishes and historical association with a particular sector, as well as last known address. In the final analysis, clinical staff should rely on goodwill, common sense and the principles of sound clinical practice in the best interest of the patient. Homeless patients are patients who currently do not have a substantive address anywhere in New South Wales; substantive addresses do not include crisis accommodation; shortterm accommodation facilities or refuges. Revision no. 0 Document No. T13/4338 Date: January 2013 Page 12 of 20

13 Full Occupancy & Emergency Bed Management All sites are required to have demand management plans in place to ensure early notification of at or near capacity status and to facilitate a rapid operational response. There is a repertoire of operational priority options that can be assertively undertaken to facilitate self-management and ensure site self-sufficiency. The following options should be considered, but only where safe and clinically appropriate: Identify Out of District patients who may be considered for repatriation. Identify patients who may be considered for transfer and admission to a private mental health facility. Identify and review status of any clients on leave, but only where this is safe and clinically appropriate. Identify clinically appropriate patients, above and beyond those who have been identified for planned discharge, who could be considered for early/ emergency discharge to assertive, community based mental health care. This would include reviewing bed assignments and discharge status of clients, status of any clients on leave, any client requesting to be discharged or clients who have supportive family and/or community networks in order to identify any beds that could be made available. The Consultant Psychiatrist (or delegate) is responsible for ensuring adequate notation is placed in relevant clients medical records in order for other staff members to make an informed decision regarding discharge. The notation in the medical record must include levels of risk and changeability, community and social supports, level of community mental health services support and any other follow-up arrangements which are desirable to facilitate safe discharge. The final authority regarding discharge rests with the Medical Superintendent (or delegate). Where a Unit has separate General and Observation areas, all reasonable attempts must be made review existing patients in observation areas for possible transfer to General, PECC or non-acute care areas. The NSW Patient Flow Portal Bed Board should be used as a tool to identify potential available beds in other units within the SESLHD. Transfer between units for bed availability reasons should occur within SESLHD initially before exploring options in other Local Health District services. The sector based Patient Flow Coordinator (PFC) or delegate should contact the respective site based PFC indicating available beds to confirm current status and discuss the potential to accept a suitable patient. Presence of an available bed on the NSW Patient Flow Portal Bed Board does not obligate a unit to accept a referral for admission. Admission Considerations Admissions where possible should be restricted to psychiatric emergencies only. Patients admitted will need to meet the requirements for involuntary admission under the NSW Mental Health Act (2007). In extraordinary instances, a voluntary admission can be negotiated where clinically appropriate. Admission of any person not meeting the above criteria should be negotiated directly with the respective Clinical Director/ Consultant Psychiatrist and relevant Senior Clinical Operations Manager. Any decision to accept an admission must be done in consultation with the respective Patient Flow Coordinator/ Nursing Unit Manager/ Duty Consultant and Medical Superintendent (or delegate). Over Census Over-census is defined as the number of clients above 100% occupancy in residence at midnight, excluding clients on leave. Admissions to leave beds are not counted as being over census. The decisions to admit over census requires consideration of acuity, ward milieu, availability of adequate staffing numbers and skill mix of staff and must be taken in consultation with the NUM and Medical Superintendent (or delegate). Each general acute and observation inpatient until must document a clear position on over census admission. These should only be considered where it is possible to provide a safe physical environment Reserving Local Beds All units should cooperate in managing peaks of demand. Units should not generally reserve available beds for local catchment patients with the exception of first episode trial overnight leave. Some exceptions to this principle are necessary. Sites reserving local beds will be overridden by the principle of district level self sufficiency. Patients should not be transferred to another LHD for admission if there are beds available within this LHD. Revision no. 0 Document No. T13/4338 Date: January 2013 Page 13 of 20

14 Over Census Admission to Medical/ Surgical Beds This option is a last resort when all other avenues for securing an appropriate mental health bed have been exhausted and only where certain conditions in relation to the appropriate and safe clinical care of the patient can be ensured. This option must be authorised by the SESLHD MHS Director. Transfers & Communication of Clinical and Risk Information Site Patient Flow Coordinators (PFC) will manage requests for transfer and admission of patients to another geographical catchment area during routine business hours. After hours the role of negotiating capacity at another mental health facility is delegated to the respective After Hours Nurse Manager/ Nurse in Charge of the inpatient unit or attending PECC or MH ED CNC. Assessment documentation including the relevant MH-OAT documentation is to be sent by fax to the provider MHU prior to the transfer to determine the patient s suitability in relation to clinical risk status and unity acuity. If the patient is accepted for transfer a negotiated care plan and a tentative repatriation date must be agreed to and documented in the patient s medical record. The MHU transferring the client is responsible for ensuring appropriate pre-transfer treatment and observation, for arranging the transfer, and for ensuring adequate communication of clinical and risk information that would include all relevant documentation of the client s assessment, a preliminary management plan and all necessary Mental Health Act and MH-OAT documents accompany the patient. In the context of over census admission and under the provisions of the Mental Health Act (2007), involuntary patients are required to be admitted to gazetted units. There are currently no gazettal units/beds in the general hospital wards in SESLHD. This policy statement does not cover the transfer of an involuntary patient to a general hospital bed for medical care as authorized by the Medical Superintendent. In the circumstances where an appropriate mental health bed cannot be located, then consideration may be given to admission of a mental health patient to a general medical bed. This can only happen if the following requirements are met: 1. The mental health service is responsible for the medical and nursing care of the patient and associated costs. 2. The admission is to be authorized by the Consultant Psychiatrist responsible for the care of the patient, the site Service Mental Health Director, the Facility Executive Director and the SESLHD Director of Mental Health Services. Each site- based service will develop clear guidelines for assigning the care of the patient to a Consultant Psychiatrist (e.g. whether the care is provided by a Consultation- Liaison or Acute General Psychiatrist or Psycho geriatrician will depend on local circumstances and the patient s requirements). 3. The patient is voluntary and the clinical and risk profile of the patient means that supervision can be appropriately provided in a general ward setting. The availability of nursing staff with expertise in mental health appropriate to the level of care required by the patient must be confirmed before the admission can be authorized. Medical staff a r e r esponsible for authorizing the appropriate observation level taking into account the usual considerations of clinical and risk status and the physical environment of the medical ward. 4. The patient is formally admitted under the care of a Consultant Psychiatrist who is responsible for the ongoing medical care of the patient in the general ward setting. Relevant mental health staff will stay actively involved in the care of the patient. 5. The clinical record should include comprehensive documentation from medical and nursing staff including care plan instructions for nonmental health trained staff. 6. The care of the patient is to be reviewed regularly through established local processes such as ward rounds. Revision no. 0 Document No. T13/4338 Date: January 2013 Page 14 of 20

15 Transfer & Repatriation Plans A transferred client needs to be returned to the primary MHU as soon as practicable. Priority should be given to the primary MHU to fill empty beds with outlying clients currently admitted in other Emergency and general hospital wards; however this should not override clinical need. If a client has been transferred to a MHU from another MHU within SESLHD MHS, but the client was originally from another site, i.e. a third (primary) MHU, then the responsibility lies with the primary site to take the client back when the first bed becomes available. A client requiring on-going in-patient care should be returned to the primary MHU. However, if the client does not require further in-patient care, then the primary sector community mental health team must take charge of this client s on-going management following discharge from the provider MHU. For example, if a client was transferred from the Kiloh Centre, POWH to St. George, but was originally from Sutherland, then the responsibility falls to Sutherlands to find the client a bed in their M H U or f o l l o w -up from the Su the rland Community Mental Health Team, whichever is applicable. Community follow up must be attended to within seven days of discharge. The provider MHU is responsible for arranging transport back to the primary MHU when a bed becomes available and for ensuring all relevant risk assessments and documentation, including original Mental Health Act 2007 documentation and referrals to either hospital or community health services, have been completed and sent. The provider MHU within SESLHD MHS is responsible for an appropriate handover of clinical and risk information. Where an out of District patient is discharged from a general acute or observation inpatient unit to their local community mental health services, it is the responsibility of the discharging unit to arrange appropriate referral and follow up within seven days. The decision to accept a Non SESLHD admission is not only based on the presence of an empty bed within a site. The site MHU should make a decision based on prevailing SESLHD MHS circumstances as an entity. SESLHD MHS operates on the understanding that where a bed is not available at the respective site within SESLHD for an acute MH admission within ED, negotiations with another MH site within SESLHD MHS will be requested and given high priority. Non SESLHD MHS Bed Requests When there is a request from another LHD to admit a client into an available bed within SESLHD MHS these procedures are to be followed in this order: Appropriate clinical information should be requested in writing and forwarded via fax to determine suitability of client and acceptance of transfer. The assessing clinician should convey all relevant clinical information. The decision to accept an admission is not only based on the presence of an empty bed. The provider MHU should make a decision based on prevailing SESLHD MHS circumstances. These circumstances may include: ward milieu, staffing levels, skill mix of staff, acuity or outliers, i.e. potential clients being held in Emergency D e p a r t m e n t s or a person known being transferred by community mental health team, police or ambulance to the MHU. Any decision to accept an admission must be done in consultation with the PFC, NUM, Duty Consultant and Medical Superintendent (or delegates). If the patient is accepted for transfer, a negotiated care plan and a tentative repatriation date must be agreed to and documented in the patient s medical record. The MHU and/or LHD transferring the client is responsible for ensuring appropriate pre-transfer treatment and observation, for arranging appropriate transfer, and for ensuring adequate communication of clinical and risk information, and relevant original Mental Health Act 2007 documents. The provider MHU within SESLHD MHS is responsible for arranging transport back to the primary MHU and / or LHD as soon as a bed becomes available. The provider MHU within SESLHD MHS is responsible for an appropriate hand-over of clinical and risk information. Priority will be given to returning clients to other MHUs and LHDs as soon as beds become available. Revision no. 0 Document No. T13/4338 Date: January 2013 Page 15 of 20

16 Special Flow Circumstances The SELSHD MHS Access and Service Integration Manager can be contacted directly to assist with special patient flow circumstances where deliberate admission to another unit may be advisable or necessary (e.g. employee of the Health Service, sexual safety risk, risk to third party). Other special patient flow circumstances include; Demand surge, Out Of District negotiations, Deliberate admission to another MHU or service, Expeditious transfer Site based barriers to flow Administrative barriers to patient flow Transport challenges Special needs populations Process for Resolving Disagreements From time to time disagreements arise regarding the use and management of mental health beds. Police Beds Prince of Wales accepts Police presentations to the MHU rather than via the Emergency Department (ED). A dedicated allocation of both a police and ED demand bed is current practise to allow for such admissions. Local a g r e e m e n t s have been developed between the ED and POW MHS Director to cover the eventuality where the MHU is unable to accept further police presentations. In the event of a dispute, or if a decision cannot be made, the Consultant Psychiatrist (or delegate) should contact the relevant Consultant Psychiatrist of the provider MHU in order to arrive at a workable solution. If the Consultant Psychiatrist (or delegate) requires further clarification before a decision can be reached, discussions should occur between the relevant MHU Medical Superintendents then between the relevant site Service Directors until a decision can be reached. After hours, the site Executive on call will facilitate these negotiations. As a last resort, consultation should occur between the SESLHD MHS Director and the respective District MHS Director. Each service site needs to cater for local demand and develop a system involving Mental Health and the Emergency Department to ensure that emergency presentations can be managed locally. Revision no. 0 Document No. T13/4338 Date: January 2013 Page 16 of 20

17 Operational and Clinical Bed Management In the context of Patient Flow the processes around bed management are divided into three distinct but parallel practices operational, clinical and strategic bed management. Operational Bed Management is defined as the administrative tasks associated with locating an inpatient mental health bed inclusive of bed finding and/ or negotiations between services regarding bed availability, repatriation and identifying suitable patients for clinical review / for leave, transfer or admission to a private mental health facility. Clinical Bed Management is the process around clinical decision-making including the following: Clinical review of Out of District patients who may be considered for repatriation. Clinical review of patients who may be considered for transfer and admission to a private mental health facility. Review clinical status of any patients on leave for extension of leave. Review the identified clinically appropriate patients, above and beyond those who have been identified for planned discharge, who could be considered for early/ emergency discharge to assertive, community based mental health care. This would include reviewing bed assignments and discharge status of patients, status of any patients on leave, any patient requesting to be discharged or patients who have supportive family and/or community networks in order to identify any beds that could be made available. The Site Patient Flow Coordinator or Nurse In Charge of Shift (After Hours) of each respective Mental Health Acute Inpatient Unit is responsible for site-specific beds & operational patient flow. On-call Psychiatry s should not take the operational role of after-hours patient flow manager, or be primarily involved in bed finding and/ or negotiations between services regarding bed availability. However on call/ on duty Psychiatry s, together with the on call/ on duty Consultants do have explicit responsibilities in clinical bed management and clinical process in the transfer of clients between services. Bed Management Bed Request SESLHD MHS Local Patient Flow Coordinator or Nurse In Charge of Shift (After Hours) facilitates access to site Mental Health Bed If no immediate capacity the proceed to Operational / Clinical Bed Management processes Operational Bed Management Patient Flow Coordinator Clinical Bed Management On-call/On-duty /Consultant Parallel but distinct process to source Mental Health beds Strategic Bed Management is the process around data monitoring/interpretation. This includes KPI monitoring (e.g. Emergency Access Performance,>24 hrs in ED & 28 day re-admission rate) and data related to acute bed utilisation (bed occupancy, length of stay, admission rates & separation rates) to support the effective utilisation of acute beds across SESLHD MHS. Revision no. 0 Document No. T13/4338 Date: January 2013 Page 17 of 20