Mental Health Telephone Triage:‘…from the ground up.’

Mental Health Telephone Triage: ‘… from the ground up.’

Dr Robert Colgate Consultant Psychiatrist and AMD WHSSC Bridgend and Caerphilly 2018

Triage • What do you know about the mental health triage scales or referral algorithms?

Triage • What do you know about the mental health triage scales or referral algorithms?

• A1 I have heard or seen one • A2 I have used one in work • A3 Not a clue

Triage • What does ‘dislocation’ mean in the context of mental health telephone triage?

Australia Mental Health Triage scale • Generic triage categories developed steadily in Australia from 1977 onwards • Specific Mental Health scales from 1988 focussed upon Accident and Emergency units • National (Australian) five point scale agreed in NICE (Australia) guidelines in 2005

Australia Mental Health Triage scale • Retains five point colour coded structure, now labelled category B through to category F • Additional categories: • Category A: Immediate – current actions endangering self or others • Category G: Advice or information only OR more information needed

University of Melbourne • Natisha SANDS • Stephen ELSOM • Publishing key research into competencies and decision algorithms • Focus upon Adult Mental Health services

Old Age Psychiatry (Bridgend) • Referral coordination pathway set up in 2002 • Operates 09:00 to 17:00 Monday to Friday • Service focussed around a referral algorithm using three categories (triage) plus advice • Risk assessment @ point of referral • Decision lead by clinical referral coordinator • Not directly involved in assessment or delivery of clinical interventions

Summary of Training • Improving and developing rapport including telephone triage techniques • Allocation of triage categories using hybrid scale based on the Australian Mental Health Triage scale and Old Age Psychiatry algorithm • Addressing the differences between mental health triage allocation and service delivery • Known as ‘dislocation’ or as ‘dissociation’

Who Decides?

• Using triage scales inevitably produces decisions which will affect service staff activity • Using these systems, the decision of the individual processing the referral is vital • Respect the decision • Assessment first / feedback later • Frequent challenges to the triage decisions can seriously undermine the whole process

UK Mental Health Triage Scale (Draft)

Triage Code / description

A Emergency

B

Very high risk of imminent harm to self or to others

Response type / time to face – to face contact IMMEDIATE REFERRAL Emergency service response

WITHIN 4 HOURS Very urgent mental health response

Typical presentations

Current actions endangering self or others Overdose / suicide attempt / violent aggression

Acute suicidal ideation or risk of harm to others with clear plan or means Ongoing history of self harm or aggression with intent Very high risk behaviour associated with perceptual or thought disturbance, delirium, dementia, or impaired impulse control Urgent assessment under Mental Health Act 1983 Initial service response to ‘front of hospital’ ward areas

C

High risk of harm to self or others and/or high distress, especially in absence of capable supports

D

Moderate risk of harm and / or significant distress

E Low risk of harm in short term or moderate risk with good support / stabilising factors

F

Referral not requiring faceto-face response from mental health

G Advice, consultation, information

WITHIN 24 HOURS Urgent mental health response (SAME DAY RESPONSE)

WITHIN 72 HOURS Semi-urgent mental health response

WITHIN 4 WEEKS Non-urgent mental health response (OR WITHIN 5 WORKING DAYS FOR LIAISON) Referral or advice to contact alternative provider

Advice or information only OR More information needed

Suicidal ideation with no plan or ongoing history of suicidal ideas with possible intent Rapidly increasing symptoms of psychosis and / or severe mood disorder High risk behaviour associated with perceptual or thought disturbance, delirium, dementia, or impaired impulse control

Mental health service action / response

Additional actions to be considered

Triage clinician to notify ambulance, police and / or fire service

Keeping caller on line until emergency services arrive / inform others

Liaison, Psychiatrist or CRHT face-to-face assessment AND / OR Triage clinician advice to attend a hospital A and E department (where the person requires medical assessment / treatment) Liaison, Psychiatrist CRHT or CMHT faceto-face assessment

Requires specialist mental health assessment but is stable and at low risk of harm during waiting period Other services able to manage the person until mental health service assessment (+/- telephone advice) Known service user requiring non-urgent review, adjustment of treatment or follow-up Referral for diagnosis (see below) Requests for capacity assessment, service access for dementia or service review / carer support Other services (outside mental health) more appropriate to current situation or need

Patient or carer requiring advice or information Service provider providing information (collateral) Initial notification pending further information or detail

Telephone Support.

Point of contact if situation changes

Contact same day with a view to following day review in some cases Obtain and collate additional relevant information

Overt / unprovoked aggression in care home or hospital ward setting Wandering at night (community) Vulnerable isolation or abuse Significant patient / carer distress associated with serious mental illness (but not suicidal) Absent insight /early symptoms of psychosis Resistive aggression / obstructed care delivery Wandering (hospital) or during the day (community) Isolation / failing carer or known situation requiring priority intervention or assessment

Recruit additional support and collate relevant information

Telephone support and advice to manage wait period

Liaison, Psychiatrist or CMHT face-to-face assessment

Telephone support and advice Secondary consultation to manage wait period

Liaison, out patient clinic or CMHT faceto-face assessment

Telephone support and advice

Advice to contact other provider and/or phone referral to alternative service provider (with or without formal written referral)

Assist and/or facilitate transfer to alternative service provider

Triage clinician to provide advice or collect relevant information

Consider courtesy follow up telephone contact

Telephone support and advice

Telephone support and advice

Specific issues: Referral for diagnosis usually category E with psychiatrist as either hospital liaison (5 days), home visit or clinic (within 4 weeks). Walk in clinics will be used to manage some referrals, typically categories B, C and D – categorise as per need.

Lithium notification – typically category D plus discussion with psychiatrist Drugs for dementia notification – typically category D plus discussion with drugs for dementia team Possession of firearms or weapons – typically category A or B – discuss with senior psychiatry staff Driving licence assessment – typically category D plus discussion with senior psychiatry staff Sands, N. Elsom, S & Colgate, R. 2014. Adapted from the Victorian Mental Health Triage Scale (Victorian Department of Health, Australia) and the Old Age Psychiatry referral algorithm (Colgate, R & Jones, S.)

Case Study 001

Case Study 002

Mental Health Telephone Triage • Development

• Domains

• • • •

• • • •

Essential Proficient Strong Exemplary

Algorithm Staffing Access Dislocation

Hierarchy Essential (Outline)

Proficient (Skeleton)

Hierarchy (continued) Strong (Muscular)

Exemplary (Portrait)

Algorithm (1) • essential: • recognised list of referral categories but without timescales or with an inconsistent service response • [insufficient: no recognisable list of referral categories]

• proficient: • established set of categories of patient need with a defined service response time

Algorithm (2) • strong: • clearly defined and comprehensive range of referral categories with associated response time scales : limited testing of outcomes

• exemplary: • well established algorithm which has been practically tested in the field over more than three years including testing with critical incident review or complaints

Staffing (1) • essential: • referral management recognised as a clinical function

• [insufficient: clerical staff still retain major responsibility for sorting referrals]

• proficient: • training in referral triage offered to the qualified staff who manage referrals

Staffing (2) • strong: • staff who triage or manage referrals receive specific training and opportunities for clinical supervision

• exemplary: • robust system of triage training and refresher updates associated with systematic supervision of routine and adverse referral incidents

Access (1) • essential: • recognition that urgent calls should be directed to a single point

• [insufficient: no clear or identified fast track process for urgency]

• proficient: • allocation of a single number to receive urgent referrals

Access (2) • strong: • promotion of a single point of access for both urgent and non urgent referrals to non mental health staff

• exemplary: • robust and well publicised single point of access for all postal, telephone, e mail and fax referrals or enquiries

Dislocation (1) • essential: • allocation of referrals responsibility to single senior member of staff

• [insufficient: no clear attempt to separate referral triage from service delivery]

• proficient: • delegation of triage responsibility to specific staff for certain days on a pro rata basis

Dislocation (2) • strong: • triage of referrals crystallised around staff whose sole (or main) responsibility is triage

• exemplary: • stable system over more than three years with local collective decision made about permanent or rotational appointment for triage

Governance • • • •

Essential for quality improvement Requires commitment of time Answers the question : ‘ What do we do about G … ? ’

Summary • Mental health telephone triage is fully established as an effective service model • Widespread in Australia since late 1980s • Local experience in South Wales since 2002 • Formation of a common language between services and community is a key component

• Robert.Colgate@wales.nhs.uk • Robert.Colgate2@wales.nhs.uk (WHSSC)