Abstract
In government of a state, then, the hardest thing is to recognize the worth of others, not to rely upon one's own.
Giles 1959, Lieh Tzu
Canberra and the associated Australian Capital Territory (ACT) are an enclave nested within New South Wales (NSW). The total population of Canberra is approximately 350 000, with approximately 26 000 persons over the age of 65. It remains a relatively young city, with the median age being approximately 32 years. Canberra serves as a regional centre for surrounding areas in NSW. It is within the ACT that the majority of specialist medical services for the region are concentrated.
The population of Canberra has grown from approximately 150 000 in 1970 to the current population of approximately 350 000. The older people in this community comprise those who have been long-term residents, generally concentrated in the older suburbs around the original city centre of Civic. With the influx of persons taking up employment in the civil and private sectors within the ACT, there has been some migration of the older relatives of these people. Thus, within the newer areas of expansion towards the north, north-west and southern areas of Canberra, there are pockets of elderly people among the general population of much younger, single people and young families. Furthermore, it has remained a location in which it has been difficult to recruit skilled health professionals and support staff.
THE CHALLENGE
Until 1999, there was no specialist mental health service for older persons within the ACT. In 1999, a consultant psychiatrist with subspecialist qualification in psychiatry of old age was appointed on a parttime basis, and with the appointment of an experienced registered nurse in Older Persons Mental Health, the nucleus of the ACT Older Persons Mental Health Service was formed.
At this stage, three major obstacles were to be overcome. First, there was a lack of direction from executive levels of the ACT Health Service regarding development of a de novo service. Second, there was no provision for administrative support or infrastructure, such as computers, office equipment, telephones, or other essentials of providing a service. Third, there was the administrative burden of managing a budget without the appropriate business management support.
As a result of these factors, the psychiatrist and team leader had to develop de novo terms of reference for the service, job descriptions and plans for resource allocation, establish systems for contact with other services and engage in strenuous attempts to advocate for appropriate resources in order to deliver service to patients.
SERVICE DEVELOPMENT
The constraints of having only two health professionals meant that service delivery had to be constructed around a consultation-liaison psychiatry model, with liaison being offered to other service providers, both within the community and the health system. Consultation was provided to non-governmental organizations, such as the Alzheimers Association and Carers ACT. Consultation was also offered to specialist health-care services, such as geriatric medicine, community mental health teams, aged care assessment teams, general practitioners (GPs) and residential care/aged care facilities.
This initial service model involved comprehensive assessments performed by the slowly growing core of clinicians who provided assessments and detailed correspondence and liaison with referring agents. However, the execution of further plans for management and ongoing monitoring of patient care had to be performed by the referring agents, and in the majority of cases this was provided in partnership, in the main, by GPs. Medical, nursing and allied health staff were required to perform initial assessments, as well as to provide liaison and support to GPs, mental health case managers and residential care staff, among others. Understanding the constraints of the short-staffing of the service, these colleagues became partners in care-delivery.
By the end of the first year, it became important to obtain funding to allow for forward strategic planning for Older Persons Mental Health Services within the ACT. The service was awarded a Commonwealth grant in order to employ a project officer to conduct a formal review of the Older Persons Mental Health Services within the ACT. The project officer was supervised by the psychiatrist and overseen by a steering committee with representation from Carer, Medical Specialist Groups, Mental Health and ACT Health. In addition, the project officer worked clinically within the service and thus was able to appreciate its day-to-day nuances. After a review of the literature and service developments for Older Persons Mental Health nationally and internationally, a model similar to the Victorian model for development of Older Persons Mental Health Services was adopted.
The collaborative model evolved gradually. It was based upon the GP, the primary service provider. Essentially, this consisted of a shared care model, with communication by comprehensive reports, letters and telephone communications on every patient assessed. There were parallel education initiatives, such as evening seminars and yearly seminars to GPs and associated providers. Uniquely, the service employed a GP as part of the multidisciplinary team. The GP began to assess issues in relation to general practice and developed a survey to assess GP satisfaction with service delivery and support from the Older Persons Mental Health Service. In response, a guidebook for primary healthcare professionals is being developed.
In addition to this, there were several collaborative exercises with other agencies involved in the delivery of older persons' health care. The Aged Care Assessment Team (ACAT) was engaged in a working party to develop links in relation to shared responsibility and to identify gaps in service provision to our shared patient group. A Memorandum of Understanding and protocol, in terms of service delivery and coverage, was developed with ACAT, Adult Mental Health Services, the crisis team and the geriatric medicine unit. Following these protocols, pathways of care were developed and ongoing networking meetings were held on a 6 monthly basis for all community service providers.
New collaborative meetings and seminars facilitated the exchange of relevant clinical information, paved the way for joint assessments with other service providers and maintained ongoing linkages in relation to communication and cooperation in service provision for older persons.
PROVISION OF EDUCATION
The Older Persons Mental Health Service has maintained linkages via frequent formal and informal education sessions to other service providers. There is also an Older Persons Mental Health Service clinicianled interest group, to which the other service providers are invited and which is held monthly, with presentations from local service providers or invited speakers on topics related to older persons' mental health. These seminars have proved successful and are the point for much interaction between various services. They are further supplemented by yearly seminars with prominent interstate keynote speakers. As part of the ongoing education provision and sourcing for ideas in terms of service delivery, senior members of staff have assessed interstate services, particularly the Victorian Mental Health Services, and established collaborative networks for the assessment of other State services.
FURTHER DEVELOPMENT OF THE OLDER PERSONS MENTAL HEALTH SERVICE
Further development has been predicated on consistent leadership, with the original clinical directorship remaining stable during the first 5 years of the service. Employee recognition awards (2004) were received in recognition of the establishment of the service from Canberra Hospital. This consistency in approach, as well as provision of a flexible, adaptable working pattern, has contributed to good staff retention and has fostered commitment to the patient group. 1 Furthermore, by being the last State or Territory in Australia to develop psychogeriatric services, the ACT was well-placed to adapt and improve upon other States' successes in service development in this field.
The team has built up gradually over the last 5 years, with appointments of administrative support staff, registered nurses, registrars in psychiatry, psychologists, enrolled nurses and social workers. It is also notable that we now have a number of senior staff across these professions within our service, so that we have a pool of expertise to call upon to provide support and care to older persons. In addition, our links with general practice have been strengthened by the employment of a full-time equivalent GP within the Older Persons Mental Health Service to form a truly multidisciplinary team.
Further service development has also occurred in that the Older Persons Mental Health Service now provides comprehensive support and care to patients over the age of 65 within the Adult Mental Health Service Inpatient Unit. A partnership has also been developed with the Department of Geriatric Medicine for provision of cross-funded inpatient beds for older persons with mental health problems within the Geriatric Medicine Inpatient Unit. Another initiative has been the provision of 10 beds at an aged care residential facility within the local service; we provide assistance with the care of persons with mental health issues within this facility.
ESTABLISHMENT OF AN ACADEMIC DEPARTMENT
In December 2002 an academic component of the service was introduced with the establishment of the Research Centre for the Neurosciences of the Ageing (RESCENA), a multidisciplinary research centre with an academic old age psychiatrist and an office manager. Seeding funding was given for appointment of a research officer. This was the first aged mental health clinical research facility established in ACT Health. Staff at the centre have been recognized by national and international research awards, including a NSW Institute of Psychiatry Research Fellowship, RANCZP New Researcher Travel Award, RANZCP Organon Junior Research Award, International College of Geriatric Psychoneuropharmacology Junior Investigator Award and an Australian American Fulbright Scholarship (2004). Staff also serve on learned committees such as the RANZCP Board of Research and the Federal AMA Committee for the Care of Older People.
The Research Centre builds on the links that senior clinicians in psychiatry, nursing and social work have with their local universities. We now have the first senior registrar undertaking accredited Fellowship training for advanced qualifications in old age psychiatry in the ACT. A scholarship student is enrolled in the first joint MPhil programme betwen the Medical School and School of Psychology, Australian National University (ANU). The Research Centre has contributed to teaching and education within the local service, both at the undergraduate and postgraduate levels. Teaching is provided to GPs and within medical and nursing specialties. Currently, student placements and teaching occur for graduate medical students from the University of Sydney Graduate Medical Programme and for students in the new ANU Medical School.
There is collaborative interdisciplinary teaching with the Nursing Program at the University of Canberra and the Mental Health Nursing Diploma students from Latrobe University. Links have been established with the ANU School of Psychology in relation to supervision of students' research projects.
The Research Centre has established formal links and collaboration with several organizations, including:
the Centre for Mental Health Research at the Australian National University (longitudinal ageing and population intervention studies); the Academic Department of Consultation Liaison Psychiatry (studies to investigate neuropsychiatric aspects of late life depression and one-carbon metabolism and genetics); the Academic Unit for Psychological Medicine, Canberra Clinical School, University of Sydney (projects on cognitive behaviour therapy for post-traumatic stress disorder); the Neuropsychiatric Institute, Prince of Wales Hospital and University of New South Wales (neuroimaging research on the sequelae of stroke) the Department of Neurology, Canberra Hospital (Neuropsychiatric Movement Disorders Clinic and research programme); the ANU School of Psychology (research into cognitive and emotional processing of depression in Parkinson's disease); and Carers ACT and the Department of Health, Ageing and Veterans Affairs (aged care evaluation research regarding innovative respite care for behavioural and psychological symptoms of dementia).
CHALLENGES FOR THE FUTURE
The major challenge is to establish a more cohesive and Territory-wide service. There is ongoing collaboration with Aged Care Services in terms of shared care, in order to provide comprehensive care for aged persons.
A designated inpatient facility with appropriate architecture and staffing to support the care of older persons' mental health in relation to severe mental illness is seen as a great priority for the service. In addition, there should be step-down care such as extended care beds for medium-term care of those with psychiatric illness, and those with behavioural and psychological symptoms of dementia. Provision of day programmes for rehabilitation of those with longstanding illness and support for carers is also a priority.
Although the infrastructure can be provided for establishing an inpatient facility and the specialist extended care services as well as outpatient day programmes, Canberra's relative geographical isolation remains a crucial issue in recruiting and retaining skilled staff and maintaining their interest in our service.
We believe that the commitment of both the local and executive leadership towards consistent and collaborative approaches to care are the foundations for development of such a service. 1 However, against an increasingly competitive environment, it is important to provide opportunities for service improvement and quality improvement, to maintain expertise and to reflect upon the clinical care we provide, in order to provide the best possible care for our patients. 2–3 The academic component of the service seeks to provide opportunities for staff within and outside the service to collaborate on innovative research and thus to contribute to professional development and service improvement. This will further our ability to recruit, educate and retain the skilled and dedicated staff that comprise the service. With ongoing collaboration in care, education and research, we believe that we can provide the best possible standard of mental health care that would be expected for the national capital's older citizens.
Footnotes
Acknowledgements
We thank Ms Jane Cure for editorial assistance.