Introduction:
People living with severe & enduring mental illness have a 14-23 year reduced life expectancy compared to the general population, primarily due to cardiovascular disease and metabolic syndrome rather than suicide. Mental health consumers tend to receive poorer quality physical health screening and have reduced access to health care, as well as being less likely to engage in healthy lifestyle behaviours.

Short description of practice change:
Sydney LHD, in collaboration with the local Primary Health Network, has introduced a Mental Health Shared Care program across ten community mental health teams. This uses a mental health shared care checklist to formalise agreements between care coordinators, consumers and their GPs.

Aim and theory of change:
The aim is to improve the physical health of mental health consumers through integrated care provision, while improving lines of communication between public mental health services and primary health. The checklist sets out clear lines of responsibility for the individual services to undertake, including actions related to screening, information sharing and physical health interventions.

Timeline:
There was a successful pilot in 2017 with two of the smaller teams. Since January 2018 the program has been implemented across all care coordination teams in Sydney LHD. The checklist itself sets out expectations in line with an annual cycle of care.

Highlights:
From the pilot stage until present, engagement with the program has increased from 5% to 33% of community consumers receiving joint physical and mental health care across service domains, translating to approximately 600 current consumers being engaged with the program, plus many more who have since been discharged from mental health services. The program is now moving into a phase of reviewing whether the checklists are being adhered to, e.g., tracking the annual physical examinations with GPs.

Comments on sustainability:
The program is not without its challenges, but despite these there is good evidence emerging that formalising share care arrangements with GPs leads to improved health screening for mental health consumers. With continued effort, including the creation of senior clinician enhancements to drive the program, there is every reason to think the program will be sustainable.

Comments on transferability:
There are approximately 1000 GPs within the Sydney LHD boundaries. A snapshot audit shows current mental health consumers are engaged with 771 different GPs. If the program can have success in Sydney LHD then it would undoubtedly be transferrable to other areas.

Conclusions:
Formalising Mental Health Shared Care with GPs can lead to improved screening, detection, treatment and management of the physical health of mental health consumers, and greater communication between mental health services and primary health networks.

Discussions:
The challenges of implementing this model are plentiful, ranging from amotivation of consumers to time constraints on GPs and care coordinators. However with the commitment of all to address the significant health disparities that exist within this vulnerable cohort, significant advances can be made.

Lessons Learned:
Mental Health Shared Care can lead to improved integration of physical and mental health in people with severe mental illness.

Introduction: Inner Melbourne Post Acute Care (IMPAC) is a state funded health program which supports people following discharge from a public hospital with a diverse range of clinical and non-clinical services, delivered by a team of clinicians, generally over the telephone.

Evidence supports contact with a community worker upon or soon after discharge to improve access to primary health care.

We identified an increasingly vulnerable cohort of clients which mainstream services were not able to support adequately in the immediate post discharge period. To respond to this, the role of the Discharge Support Worker (DSW) was created.

Short description of practice changes implemented: IMPAC developed the role of DSW in 2014, in consultation with St Vincent’s Hospital, to support discharges of our most vulnerable clients.

Aim and theory of change: The aim of the role is to engage meaningfully with clients to allow the provision of intensive, practical support to vulnerable clients, to assist in achieving better health and social outcomes.

Targeted population and stakeholders: The targeted population is vulnerable and at risk of readmission due to isolation, low socio-economic status, mental illness, homelessness, multiple chronic health conditions, reduced confidence in their health management and self-care, and/or a history of poor engagement with services.

All agencies who refer to IMPAC, including hospitals and any other health agency who is involved with a client who has presented to a public hospital in the past 28 days are key stakeholders.

Timeline: The role was created in August 2014.

Highlights: The role has proven to be responsive, flexible, dynamic and collaborative, and has achieved significant outcomes for clients. Referrers are very engaged with IMPAC, which allows us to work collaboratively to achieve better outcomes.

Sustainability and transferability: The role requires a highly skilled worker as they are required to work autonomously and react quickly, with client behaviours or environments which are very challenging. The DSW is very well supported by the IMPAC Program Manager and other clinical staff, who help to formulate a care plan for each client.

The role was initially offered to clients who were discharged from STV, but the model has proven to be transferable across all hospital and community settings.

Conclusions: The DSW role has successfully supported upwards of 100 client contacts each year (2018=193) through meaningful engagement and practical support. Our stakeholders have provided very positive feedback on this innovative approach to integrated care.

Discussions: By providing a highly skilled welfare worker to work directly with the program's most vulnerable clients, we have successfully reduced hospital re-admissions, improved well-being of clients, and redirected our senior clinical staff to focus on more complex clinical issues that often present in the post discharge period.

Lessons learned: Since creation, demand has increased significantly, with significant program budget spent on material aid and industrial cleans. Boundaries around what is reasonable and unreasonable must be clarified, in order to protect future program budget, and to protect the primary purpose of the DSW.