INTRODUCTION

Although there is evidence for the effectiveness of older persons’ mental health services (OPMHS) (Draper 2000), the most effective components of such services have not yet been clearly identified. There are many different ways to deliver community mental health services to older people. This chapter covers models of care delivery and associated organisational issues. It assumes the presence of a national health service with universal access.

AREA-BASED SERVICES

In countries with national health systems, such as Australia, New Zealand and the United Kingdom, most public sector mental health services are organised and delivered within a defined geographical area or district. Inpatient beds and mental health teams are generally provided on an historical basis with forward planning of both bed numbers and community teams determined by population data. Subspecialty mental health services such as OPMHS teams are a more recent phenomenon and in many places have been grafted on to adult mental health services.

The OPMHS is likely to see people with a wide variety of mental health problems. However, in comparison with adult mental health services, the older persons’ service is likely to see a higher proportion of women and more people with mood disorders and cognitive disorders.

In more fortunate districts, acute inpatient mental health facilities for older people have been purpose-built and are co-located with geriatric medical services. More commonly, however, older people with mental health problems are admitted to general adult inpatient wards. This is often a rather unsatisfactory situation because the needs of younger people with, for example, acute psychosis are quite different from the needs of older people with, for example, severe depression. Because of their physical frailty, older people are vulnerable to falls. Some older people with cognitive impairment are prone to wander into other people’s rooms, precipitating retaliatory assaults. In addition, older inpatients often require substantially more physical nursing care and more medical interventions, mandating a quite different staffing mix. Wards with mixed groups of younger and older people often have difficulty providing for the needs of each group.

Because community mental health services for older people are a relatively new phenomenon in most places, their implementation has generally been planned. However, some districts have autonomous community-based services and others have integrated hospital and community services. This particular issue is dealt with in more detail in Chapter 5.

While larger provincial towns often have their own OPMHS, in rural and remote regions, mental health services for older people are generally provided by a lone mental health worker who must cover a vast geographic area, usually in an off-road vehicle. In some rural locations, there are fly-in fly-out mental health teams that augment the work of the local worker.

INTEGRATED HOSPITAL AND COMMUNITY SERVICES

An integrated model of hospital and community care is useful for the management of complex problems in older people with serious mental health problems such as major depression with psychotic features, bipolar disorder with comorbid physical problems such as Parkinson’s disease, and very late onset schizophrenia-like psychoses complicated by dementia. In each example, the combination of complexity and severity mandates access to hospital beds, but chronicity mandates assertive community follow-up. In such cases, the integrated hospital and community model allows essential continuity of care.

In integrated hospital and community care, the inpatient and community parts of the service share personnel, have common team meetings and share case notes. In an integrated service, the hospital team knows well the strengths and limitations of the community team and can better judge when it is appropriate to discharge a person. Similarly, the community team knows well the strengths and limitations of the inpatient team and can better judge which people are likely to benefit from inpatient care. The community team might also be better able to judge when an illness has reached the stage where inpatient care is needed. In addition, access to certain types of treatment, including electroconvulsive therapy (ECT), is often restricted to inpatient units.

For practical reasons, not all personnel can be shared. For instance, the requirement of shiftwork for most inpatient nursing personnel means that they are less likely to be able to participate much in community care. However, most allied health workers such as social workers, occupational therapists and clinical psychologists are able to work across the inpatient and community parts of the service. Similarly, most medical personnel, including psychiatrists and trainee psychiatrists (registrars), are able to work across both sectors. It is also often feasible to rotate nursing and junior medical staff between community and inpatient roles so that they are familiar with both.

In integrated services, team meetings (including ward rounds) are attended by representatives from the inpatient unit and from the community team. In some services, completely integrated meetings are held in which inpatients and those people in the community are discussed, although these can be rather lengthy. In other integrated services, separate team meetings are held with the inpatient and community teams, with representatives from the other team in attendance. There are great advantages in having cross-representation at team meetings or ward rounds. These include both teams having advance notice of impending admissions and discharges, and a larger group of health workers to share the responsibility of providing care for challenging people.

One major advantage of integrated services is the early involvement of community case managers in the care of inpatients who have not previously been case managed and the continuing involvement of community case managers where the person has been admitted from their care. Early engagement of case managers during the inpatient phase of clinical care can greatly facilitate discharge planning and allow this to begin at the time of admission.

Community case managers bring with them a wealth of knowledge about individuals patients and this can be used to facilitate an early commencement of inpatient treatment, as work-up time can be minimised. Community case managers can often introduce the person to the inpatient unit and the inpatient staff. They can also introduce the person’s family to the inpatient team. Each of these steps has the potential to make the transition to inpatient care less traumatic for the person and their family. It might also make the whole inpatient treatment phase more efficient, with reduced length of stay.

There is nothing more irritating to busy mental health workers than missing clinical files. These are a common occurrence when hospital and community mental health services within the same geographical area insist on having separate and independent clinical files. One essential feature of an integrated hospital and community mental health service for older people is a single integrated clinical file. Ideally, this would be an electronic file but, at the time of writing, in most jurisdictions this will still be a physical chart. Preferably, this clinical file should be the same file used by district medical and surgical services, so that a holistic approach can be taken to mental and general healthcare.

One perennial question is: Who covers the after-hours roster? In many mental health services, the OPMHS team is too small to cover nights and weekends in its own right, so this task is covered by a shared roster to which all teams contribute.

Australian experts (Snowdon 1993, Snowdon et al 1995) have recommended the provision of eight acute inpatient beds per 100,000 of the total population for older people with mental health problems, and British experts (Royal College of Physicians and Royal College of Psychiatrists 1989) have recommended the provision of 15 beds per 100,000 total population. However, planning documents in Australia generally specify the provision of approximately four acute inpatient beds per 100,000 of the total population for older people with functional mental health problems. They usually make no allowance for inpatient mental health beds for older people with dementia associated with severe behavioural and psychological symptoms. The net effect is that districts often have too few acute inpatient beds for older people with mental health problems, including dementia. Similarly, planning documents often specify approximately four full-time equivalent (FTE) older persons’ community mental health staff per 100,000 of the total population, rather than a number based on the number of older people and the likely prevalence of mental health problems.