Clinical Pathways: Multidisciplinary shared care plans

Project Status

Chief investigators
Mark Harris, Ben Harris-Roxas Catherine Spooner, Jane Taggart

Team members
SESLHD: Mike Gatsi, CESPHN: Mariam Faraj, Mindgardens: Jackie Curtis, Drug & Alcohol: Nicholas Lintzeris

Project Rationale

Mental health, drug and alcohol services are renowned for being fragmented, difficult to negotiate access, with multiple service providers. Services are spread across primary care settings (e.g. GPs, Allied Health in the community), private specialists in the community, specialist services in the, and increasingly a range of online and telephone support services. Patients have different types and severity of mental health and substance use problems, and it can be extremely difficult for patients, carers and service providers to find the ‘right’ service.

Many patients with MH and substance use problems also suffer from a range of physical health problems, including obesity, diabetes cardiovascular and respiratory disease that contribute to premature mortality, which can be better addressed through pathways to appropriate primary care. 

The clinical pathways project will provide an over-arching framework to build effective clinical pathways across these service providers and sectors and evaluate the model to inform future translation into other geographic areas. We will focus on a location-based model – looking at SESLHD Eastern Network area in the first instance.

The four projects that will be brought together under this project include four projects: 

1. Brief screening and referral for those patients who may not require referral to specialist services. 

2. Healthpathways between SESLHD clinicians and Primary Care utilising existing systems accessible to all clinicians.

3. Better communication and collaborative care between MH, D&A and primary care services ('Comorbidity Package') for enhancing coordinated care and collaboration between services

4. Multidisciplinary shared care plans that are compatible with eMR with the Central and Eastern Sydney Primary Health Network (CESPHN) using the systems and knowledge gained by CPHCE from our Cancer Shared Care Program. This is for patients who have active shared care treatment plans requiring regular and close communication between specialist and primary care services.  

The overall project is being conducted under the auspices of SESLHD Drug and Alcohol Service, and CPHCE is leading project 4.

Project Aim/s

The aim of the Clinical Pathways project is to ensure clinical pathways are collaboratively developed to facilitate access for patients with mental health and substance use problems, irrespective of point of entry into the system (a ‘no wrong door’ approach).

The aims of Project 4: Multidisciplinary shared care plans project are:

1. To develop a web based shared care plan that link GPs with specialist services (mental health and drug and alcohol) in the long-term management of PWSMI.

2. To implement this for a group of patients where there is agreement for this to occur (by patient, GP, mental health services)

3. To evaluate the feasibility, acceptability and experience of patients with the web based shared care plan.

Project Design and Method

The intervention will be conducted in a number of steps:

1. Scoping and agreement.  A meeting will be held to identify one service unit and group of patients for the piloting of the shared care plan.  This will specify how the patients are to be identified, the role of each of the providers involved (support or peer workers, case managers, GPs, managers, information managers) and the broad pathways of care. 

2. Development specifications.  A workshop involving all key stakeholders will be held to clearly define the role of each provider, a detailed work-flow and a list of discrete tasks to be shared (who does what, when, how over 12 months) and data elements to be included in the plan. 

3. Development of intervention.  The team will work to develop the agreed patient summary, training materials for GPs and mental health service providers.  The specifications will be used to design the template for the care plan together with the software provider

4. Evaluation plan and ethics.  An evaluation plan will be developed and registered (on Prospero).  An application for ethics approval will be submitted to SESLHD Ethics Committee. 

5. Trial initiation and recruitment:  Specialist service providers, patients and their GPs will be recruited over a 3-month period.  At recruitment providers and patients will be interviewed qualitatively. 

6. Trial implementation:  This will occur over 12 months and will involve repeat interviews and collection of health service use data from PWSMI, mental health services and GPs.

7. Evaluation and reporting:  Quantitative and qualitative evaluation data will be analysed and reported.  Presentations and publications will be prepared for policy, practice and academic audiences. 

8. Scalability:  A workshop will be held to discuss wider implementation or modification based on the evaluation. A two page plain language summary of findings will be provided to participants.