“Choice is important and crisis care systems need to make the full gamut of services available. Choice means having a variety of professions available, including peers, all of whom are able to provide the level and type of support the person desires.
Lots of us have experienced harm, but that does not mean the whole lot should be thrown out. I have experienced harm, but I have also experienced help. It is about preserving what works and transforming services to eliminate what does not.”
Lived Experience Lead, Gold Coast Mental Health Specialist Services
Across the Zero Suicide Healthcare global community, the Gold Coast Mental Health Specialist Services (GCMHSS) is seen as a leading proponent of the framework. In a short space of three years, they have reduced outmoded practices and expanded evidence-based practices that have resulted in significant improvements of the quality of care from within their services. They have also demonstrated that fidelity to the Zero Suicide Healthcare framework can reduce both re-admissions and re-attempts among people who have been placed on the Suicide Care Pathway.
Dr Kathryn Turner, Clinical Director for GCMHSS, is quick to share the responsibility for this success with her team. She told #CrisisTalk that there was recognition the service needed a different approach. At the time we dealt with suicidality through treatment for mental illness and it was clear this was not achieving the outcomes for people that the team wanted. Reviews of adverse incidents, which included suicide of people within the care of the service, did not always make recommendations that made sense. Staff were not included in reviews and therefore, more often than not, this lack of transparency and openness led to a defensive attitude to implementing change. We realised that we were seeing people who were in a suicidal crisis but not necessarily with a mental illness. Five years ago the accepted approaches did not deal with this, but fortunately the evidence was mounting that suicidal behaviour should also be treated directly, not just as a by-product of a mental illness.
Kathryn and her team began this journey in late 2015 by exploring many models. At the time Australia was doing broad community approaches to suicide prevention which had some inclusion of health service but not a comprehensive approach that would specifically guide a health service.
Good evidence was available from international groups, but the thing that drew them to Zero Suicide Healthcare was its specific focus on quality improvement in healthcare settings. It had the flexibility to explore the evidence-base for each of the seven elements and understood that to effect real change a system had to address its underlying culture.
Zero Suicide Healthcare is not without its challenges
“A change paradigm needs to look differently at what you are doing. Tweaking it does not cut it to change practice.”
Kathryn went on to say that any change management process is a challenge. We anticipated push back on the name and aspiration of zero. To overcome this, we embarked on an extensive engagement exercise gathering views of staff, talking to every team and harnessing support from those who were using our services. It became clear that people felt disillusioned with the approach at the time because they knew it was not working and therefore welcomed the concept of change.
There was also the challenge of embedding skills. One off training would not make this business as usual, so there has been a concerted and continuing effort given to training staff across the service to work with people who are suicidal. An important addition to formal training has been a mentoring approach with senior clinicians.
She explained that competing priorities in the service at the time of implementing the pathway, including an impending new Mental Health Act, meant that training was prioritised to areas with the largest volume of consumers likely to be placed on the pathway (eg. emergency department and acute care clinicians). Training to other areas such as inpatient units was slower to be rolled out. Both uptake and fidelity to the pathway were stronger in areas where training was rolled out rapidly across the teams. Uptake was much slower in areas where training was more gradual and this persisted even after training was completed. This seemed to suggest that there may be advantages to ensuring all team members are trained simultaneously just prior to launching the pathway. Being committed to a Restorative Just Culture means being committed to open, transparent and supportive conversations with loved ones following an incident, and to listen and understand their perspectives, which are at times very different from the health service’s understanding of events. The service must support its staff to have these conversations, so that we can all learn and improve as a result.
A new strategy for the region
The latest innovation is the development of a strategic direction for the region. The Gold Coast Crisis Reform 2021-2024 was released in December and it sets an ambitious goal to provide a more responsive, effective, compassionate and connected crisis system.
Inspired by the Crisis Now framework, a collective of service providers, people with lived experience, researchers and health administrators began to explore how this ambitious goal could be achieved. Following wide stakeholder engagement, there was general agreement that the components of the system with 24/7 reach into community; stabilisation centres; and a “care traffic control’ view of the system would ensure that a person in crisis would get the right service for their needs. The principles of zero suicide and trauma-informed care were critical to the expertise needed within services.
The key to realising this ambition is to build a continuum of care, not in a cyclical sense, but in terms of addressing a person’s ongoing needs appropriately so that care is matched to their needs.
It was clear, however, that the GCMHSS could not do this alone. “There is a tremendous unmet need in the community which is not, and nor should it be, the prevail of any one service. The only way to deal with addressing crises in the community is to work together and improve the pathways for consumers who are desperately trying to navigate an incredibly complex system.”
A mapping exercise was undertaken, that included multiple agencies from within the region, including the mental health service, people with lived experience, police, ambulance, Emergency Departments, Non-government organizations and primary care. All these services gained knowledge about the complexity of the system, what was available, and the benefits of a more cohesive approach.
Dr Turner explained, “just one small example of this was that police and ambulance services learned about crisis plans for consumers. Now they know they can use this as a starting point to help the person.”
Michelle Edwards, Lived Experience Lead within the GCMHSS, said that “the challenge is how to communicate to the community what is available and how they can make the best use of the available services. With everyone engaged in the strategy implementation, there is greater potential for providing a warm handover if a person needs to use another service.”
The whole system will be integrated through a communication hub staffed by health professionals. Through this care coordination, the best pathway of care for a person who connects through the dedicated 1300MHCALL line will be determined. This first contact point will plot the best approach for the person. Can their distress be settled over the phone? Do they need another service? Can we get the outreach team to attend? Should they go to a stabilisation centre or to ED?
The stabilisation centre will be the first of its kind in Australia operating 24/7 and will have the capacity to welcome the wide range of people in the community who experience mental health crisis, including those needing involuntary assessment and care. The location of the stabilisation centre was considered very carefully after visiting some centres in the US. Dr Turner explained “we considered both offsite and onsite locations but decided to go with onsite due to the potential for people to present with medical instability despite using a triage process. We also felt the proximity to ED has a two-way advantage. It will be available if a person requires medical attention and similarly if people present to ED they can be quickly moved to the stabilisation centre. While a peer first, peer last model will prevail in the service, there will be other private therapeutic and connection spaces and clinical capability built into the system.”
One of the challenges in exploring alternatives to emergency department care for people in crisis is the lack of clarity on models of care that are proven alternatives to ED. There are a range of services that are described as alternatives to EDs but each can have very different approaches and functions. To support improved clarity, there is a literature review underway to understand what evidence is available and how it can be applied to the strategy implementation, with the aim to provide a framework which will assist in categorising each model and the evidence that exists for that approach.
The perennial challenge of funding
One of the important aspects of health system reform is to more effectively manage the resources that are already in place. “This does not just mean dollars… re-orienting service is just as important,” says Dr Turner.
The inclusive approach to the strategy development has meant that there are many agencies that can bring their services into play without the actual exchange of cash. There is a Steering Committee which meets monthly to share resources, build a common language and cooperate with other services so that there is common activity. The GCMHSS is using its expertise, built through implementing the Zero Suicide Healthcare framework, to supporting local services with training in clinical assessments, safety planning, and other tools and skills developed within their service.
While the strategy is not fully funded, it will also be used to influence future funding decisions. What this means is that when funding does become available, the region is well-placed to use those funds in an effective way to improve the regional response to crisis.
What are the leadership characteristics that will make all this a reality?
From Dr Turner’s perspective, you need both a top-down and bottom-up approach to foster innovation.
Innovation has to engage all those partnerships who can make it happen. Gather all the ideas, see how they align with the evidence-base, embed best practice and if you go beyond the existing evidence-base, then test and use the results to contribute to the literature.
It is important to get away from the project concept, which generally has a finite start and finish date. We are building on a solid foundation where Zero Suicide Healthcare is now business as usual. New coordinated approaches to crisis care across the region will be a positive enhancement to our existing services.
This last word on leadership goes to Michelle:
“Courage, willingness, determination and resilience to stay the course. Without dedicated funding, it is a courageous decision to lead system change. Strong leadership will draw on the expertise of those with lived experience and promote their input so that it is valued and influences decisions and actions.
Everyone is willing to work hard when they have a leader with courage to challenge and do things differently.”
Click here to read the full Gold Coast Crisis Reform publication.
Sue Murray, International Correspondent
A health promotion advocate in Australia dedicated to improving the health and well being of all people. Throughout her career, she has focused on health for the community and has expertise in communications, education, and organisational development.
Sue currently leads the Zero Suicide Institute of Australia, which aims to support the healthcare system to understand and more effectively manage those who are vulnerable to suicide and suicidal behaviour.