MH Connext

The MH Connext care management program commenced in July 2017 and is available for Perth Metro located general practice patients.  MHConnext is a free mental health nursing case management program provided during business hours for between three to six months.  The Mental Health Nurses will work to support and meet your patient’s needs as part of their Mental Health Treatment/Care Plan (MHTP).   It does not provide psychological interventions and can be in addition to other psychological treatment (for example Better Access).

 Inclusion Criteria:

  • are 18 years and over
  • have significant clinical mental health symptoms that impact on functioning (social, personal, family, or occupational)
  • have a Mental Health Treatment Plan
  • want case management appointments by phone or by face-to-face in a Perth location of their choice
  • being managed in primary care by a General Practitioner
  • have one or more:
    • Co-existing conditions such as chronic conditions
    • Multiple social stressors such as housing, finances/Centrelink, social support
    • Alcohol and other drug support (including harm minimisation)

Exclusion Criteria:

  • In crisis or at imminent risk of suicide/self-harm
  • need an urgent admission or referral to Assessment Treatment Team (ATT)
  • Managed by tertiary/state mental health services
  • Mild mental health conditions only

MHConnext is not a crisis service and operates during business hours (Monday-Friday 9:00 – 5:00pm)

Referral forms

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The referral form above  is to be completed by GPs in the Perth metropolitan area to refer patients with severe and complex mental illness to case management services.

Case management (face-to-face)

To refer people to MH Connext face-to-face case management please sign and submit the completed form via fax to (08) 9258 3090 or email it to MH.Connext@rw.org.au. If you would like to discuss any aspects of the referral process, you can phone (08) 9350 8800 or email MH.Connext@rw.org.au

Next Steps in the Referral Process:

1. Send both documents:

          i. the completed Referral Form and

          ii. Mental Health Treatment / Care Plan

to:

          a. Face-to-face Case Management – fax on (08) 9258 3090

2. MHConnext Case Manager will send a referral receipt to the GP within 24 hours of fax/secure message received

3. MHConnext Case Manager will phone your referred patient within one business of referral receipt

4. If the MHConnext Case Manager is unable to contact your referred patient within the one business day, MHConnext will notify you and continue to phone your referred patient.

Frequently asked questions

What is case management?

Case management is a way of supporting the high-level needs of patients, by providing a consistent point of contact and connections to other support services. Once a patient is referred to the program, a regular case manager will keep the patient well informed, motivated and committed to their mental health plan. Depending on the patient’s needs, MH Connext providers will be able to deliver brief care intervention for the patient, to reduce the risk of relapse and support their path to recovery.

What is the referral criteria?

Severe and complex mental illness is characterised by a severe level of clinical symptoms and a degree of disablement to social, personal, family and occupational function. Patients need to have a mental health treatment plan to participate in the program.   It is intended as a short-term (3-6 months) support service that assists to establish the right services for vulnerable patients, as opposed to a longer-term intervention.

Eligibility is based on your clinical judgment; however MHConnext will also conduct an initial assessment of your patients’ needs upon referral.

Can you still utilise Medicare for your patients in the program?

Yes. You can still refer them to existing Medicare-subsidised services including access to the mental health professionals and team-based mental health care that is provided through MBS (Better Access) Initiative.

How will I be kept informed?

MHConnext adds to the list of options a GP can offer a patient, but case management does not replace the central role of a GP in primary care.

You will be provided with regular structured updates on your patient, including details regarding patient progress against the mental health care plan you have developed. If the case manager identifies deterioration or emergent symptoms, they will manage the immediate situation and advise you of the event and how it was managed.    Immediate actions may include accessing other appropriate mental health services or emergency services.    In all cases, follow up GP consultation is recommended to support a review of the patient’s mental health care plan.

How do I assess severity and complexity?

Severe mental illness is often described as significant clinical mental health symptoms that impact on a person’s functioning (social, personal, family, or occupational).  It is comprising of three subcategories:

  1. Severe episodic mental illness;
  2. Severe and persistent mental illness; and
  3. Severe and persistent mental illness with complex multi-agency needs.

Individuals from each of these groups can also experience complex health and social care needs, including medical comorbidities such as a chronic illness, or social care needs that require external support. This can include the need for coordinated assistance across a range of health, disability and social support agencies.

Your clinical assessment is relied on to establish that your patients will benefit from this case management program.

It is important to note that MHConnext is an intensive service for the most vulnerable patients with severe and complex needs.    It is not a substitute for acute treatments such as referral to hospital emergency departments and other forms of state-based care.

What if a patient is severe but doesn’t qualify as complex or vice versa?

If a patient has severe mental illness, you can still refer them to existing Medicare-subsidised services including access to the mental health professionals and team-based mental health care that is provided through MBS (Better Access) Initiative.

Importantly, the MHConnext program provides an additional option for you to offer patients, but other services still remain available.

This stepped care model will also include better advice for you about instances where state-based community mental health services may be more suitable for ongoing patient care. You can access HealthPathways for more information on a range of additional service providers.

How does it work?

Some patients with severe mental illness symptoms and complex issues can struggle to access the right care or receive a coordinated service and treatment.   Patients with severe and complex mental health issues often fall through the gaps in care.   MHConnext acts as a bridge between the GP and other mental health services, providing intensive care management and connections to other treatment options and services.

How is MH Connext delivered?

The MH Connext case management program is delivered in two modalities:

  1. phone-based care management and/or
  2. face-to-face care management.
How long will my patient be able to access this program?

It depends on the specific needs of your patient.   The case manager will complete a comprehensive assessment of your patient after 3 months to determine their need for ongoing support. You and your patient will be consulted as part of the review.

What kind of case management is on offer?

MHConnext service providers are expected to work alongside people with severe and complex mental illness to ensure a person-centred, recovery-oriented approach to care planning.  This can include:

  1. Working with GPs and other medical practitioners to implement the mental health plan
  2. Working with GPs and other health practitioners or allied health providers to support the delivery of a care and treatment plan
  3. Making linkages to low or no-cost service providers for care
  4. Liaising with other mental health services to support the person’s recovery and treatment
  5. Keeping GPs and other practitioners informed of any services provided and on-referrals
  6. Promoting the assessment of their physical health.

In practical terms, this might include a case manager organising a standardised health and social needs assessment of your patient, reviewing their medication, supporting the patient with regular phone or face-to-face contact, connecting them with appropriate therapy, and addressing contributing issues such as access to housing, government services or income support.

What are the qualifications of staff delivering the service?

MH Connext is staffed by experienced mental health nurses.