Clinical Practice Guidelines Index <

Access to Beds (April 1997)

• Introduction
• Access To Gazetted Beds-Key Principles
• Definitions
• Clinical Procedures
• What if the Patient is a Young Person Under 16 or an Older Person over 65?
• What Monitoring Will Take Place?
• Appendix 1: What if the Area of Origin is Unclear?-clarification examples
• Appendix 2: Child & Adolescent Services
• Appendix 3: Aged Inpatient Services

These guidelines replace previous guidelines about bed utilisation and should be read in conjunction with Program Management Circular 3/95 Accessing Services Across Regions and Areas.

These guidelines outline best practice standards and procedures for obtaining admission to an acute bed where:

• A mental health service is unable to provide that bed.
• A person who is out of area has presented to a mental health service.
• A private medical practitioner is seeking access to an acute bed.

The document Victoria's Mental Health Service: The Framework for Service Delivery laid the basis for an integrated mental health service system. Mental health services are organised on an area basis and have a single point of entry through community assessment and treatment services, which operate 24 hours a day, seven days a week. Admissions can also occur via consultation and liaison services.

Bed self sufficiency is an objective of the service system. However, occasions do arise when an area mental health service (AMHS) may require short-term assistance from another area.

The Bed Usage Monitoring Report generated by the Psychiatric Records Information Systems Manager (PRISM) is able to locate vacant beds throughout the state. Local medical record administrators can advise clinical staff how to access this information.

Access To Gazetted Beds-Key Principles

The following principles are in keeping with the spirit, intent and objectives of the Mental Health Act 1986 and are intended to facilitate the best and most appropriate treatment possible for people with a mental illness. These principles apply to adult, aged and child and adolescent program areas and both voluntary and involuntary admissions.

Public mental health services have an obligation to provide a bed for each person assessed as requiring inpatient treatment. The need for admission is determined by the service (after consultation with the authorised psychiatrist or delegate where there is any doubt). This decision must be accepted by the service where the request for a bed is made.

• A bed should be provided in the area of origin.
• When the mental health service of origin (see definition below) is unable to provide a bed, a bed within the same network or region must be made available on request. If a bed is not available a bed should be requested in the nearest most appropriate mental health service.
• Vacant beds must be made available on request.
• When a person of no fixed address presents to a mental health service, that service will become the mental health service of origin.
• Admissions to statewide specialist services will be by direct discussion and referral by the consultant psychiatrists concerned.
• The authorised psychiatrist of each mental health service will ensure that all current inpatients need continued inpatient care and that no reasonable or suitable alternatives exist for them.
• In the final analysis, clinical staff should rely on goodwill, common sense and the principles of sound clinical practice in the best interest of the patient.

Definitions

Area of Origin

The following replaces the definition of 'area of origin' in Program Management Circular 3/95. Area of origin is determined by the usual residential address of the person. (In cases of doubt, see Appendix 1, Clarification Example.)

Mental Health Service of Origin

Mental health service of origin is the service responsible for providing acute inpatient services for people in that area of origin.

Community Treatment Orders

Patients placed on a Community Treatment Order (CTO) or Restricted Community Treatment Order (RCTO) are the responsibility of the service which made the order irrespective of where they live or where they present in a crisis (unless formal transfer occurs).

Formal Transfer

Where a patient has been formally transferred from one mental health service to another, including patients on a CTO or RCTO, the receiving mental health service becomes the mental health service of origin.

High-Dependency Beds

High-dependency beds are inpatient beds that facilitate more intensive observation, treatment and safety. High-dependency beds form part of the mental health service overall capacity and are not recorded as discrete beds in the system. The decision to nurse a patient in a high-dependency bed is a local clinical decision made by staff of the receiving inpatient unit.

Held Bed

A held bed is a bed held in an acute psychiatric unit for a maximum of 48 hours for a patient who:

• Is attending a general medical service for treatment.
• Has absconded from an inpatient service.
• Is placed on rehabilitation leave, for example weekend leave. (As an exception leave over festive periods, such as Christmas or Easter, may be extended to 72 hours.)

Clinical Procedures

Procedure 1: Bed Required in Area of Origin

1.1 If the mental health service of origin does not have a vacant bed, admission will be to a held bed wherever possible. In these circumstances, the mental health service would need to determine whether another person would be suitable for discharge and management by a community service.

1.2 If the mental health service is unable to admit to a held bed, then a bed in an alternative mental health service should be sought. If possible, this should be in the same region or network. If this is not possible, a bed should be requested in the next most appropriate mental health service.

1.3 When a bed has been located, transport will be arranged. The mental health service of origin is responsible for reimbursing the admitting mental health service for the cost of services to the patient after the first 24 hours (see Program Management Circular 3/95).

1.4 The mental health service of origin is responsible for ensuring that the patient's case manager liases with the admitting mental health service. If the patient does not have a case manager, one should be appointed.

Procedure 2: Bed Required for a Person who is out of Area and has Presented to a Mental Health Service

2.1 The staff member assessing the patient must ensure that appropriate services (which may include admission) are provided, while referral is made to the person's mental health service of origin. If a bed is available, transport is arranged.

2.2 If a bed is not available, one should be sought by the service where the patient is being assessed. This would be either in that mental health service or in the next most appropriate mental health service.

2.3 The authorised psychiatrist of the admitting mental health service must provide written notification of the admission to the authorised psychiatrist of the mental health service of origin. This enables clinical care to be coordinated and financial arrangements for charging the area of origin to be made. This should occur no later than the next business day.

Procedure 3: Bed Required by a Medical Practitioner (not Employed by a Mental Health Service) for a Person who Appears to be Mentally Ill

3.1 A medical practitioner who has assessed a person as requiring treatment will contact the patient's mental health service of origin. If it is not known, they will contact the nearest mental health service to determine the service of origin.

3.2 The intake worker (name to be printed clearly on the intake form) will discuss the referral with the medical practitioner and will negotiate the most appropriate service response. Options may include a joint community assessment by the mental health service and the referring doctor, community treatment by the mental health service, a collaborative service agreement or admission to the inpatient unit.

3.3 If the patient requires involuntary treatment, the referring medical practitioner may be requested to complete Schedule 2: Recommendation for Admission of a Person as an Involuntary Patient to an Approved Mental Health Service. Once a Schedule 2 form has been completed, the person must be admitted to a mental health service and be examined by an authorised psychiatrist.

3.4 Such requests for admission will be monitored by the Chief Psychiatrist (see What Monitoring will take Place? below).

What if the Patient is a Young Person Under 16 or an Older Person over 65?

Child and Adolescent Mental Health Service and Aged Mental Health Service programs are also provided on the area of origin basis. Appendixes 2 and 3 list these services by area. The principles applying to adult services also apply to these programs. However, special considerations may arise from time to time in these programs-for example, there may be occasions when it will be in the patient's best interests to be admitted to an acute adult bed in the area of origin. The director of the mental health service should be involved in such a decision.

What Monitoring Will Take Place?

The Chief Psychiatrist will assess bed usage and visit bed-based services to monitor actual and reported vacancies and the use of held beds. Failure to gain access to a bed should be reported to the Chief Psychiatrist. Reports should specify the date of the request and to whom the request for a bed was made.

Appendix 1: What if the Area of Origin is Unclear?-clarification examples

• A person who has lived in Dandenong for six years is expelled by their spouse and presents to a service for admission. The person's area of origin will be where they have arranged accommodation.
  
  
• A young person who lives in Geelong has spent the weekend at their grandmother's house in Carlton. During their stay they suffer a relapse of their mental illness. As the patient will return to Geelong on discharge, the service in Geelong is responsible for the provision of services.
  
  
• A patient living in Mornington is admitted to the Royal Talbot for a three month rehabilitation program. During their stay at the Royal Talbot they require recommendation and involuntary admission. They should be admitted to the mental health service for Mornington.
  
  
• A person has been released from prison and requires mental health services at the point of release. The service which covers his/her residential address on release from prison shall be responsible for service provision.
  
  
• A patient of Waverley Community Mental Health Centre continues to seek treatment from the community mental health centre even after they have been a resident of Armadale for four months. If they fall ill and need inpatient treatment, they have to be admitted to the mental health service for Waverley.
  
  This patient should have been referred by the Waverley CMHC to the Junction Clinic which provides services to Armadale for ongoing management. If after transfer the patient required inpatient treatment, they would be admitted to the inpatient service for the Junction Clinic.
  
  
• A patient who lives in Brunswick, but works at Preston, displays psychotic behaviour at work and is taken to Accident and Emergency at PANCH. The patient should then be attended to by the Northern CAT service (associated with PANCH) and if necessary a bed should be arranged at Royal Park, as this is the patient's catchment area inpatient facility.
  
  
• A person presents or is taken to a police station and requires psychiatric assessment. The person should initially be assessed by the CAT service where the police station is located. Subsequent arrangements should be based on the patient's catchment area.
  
  
• A patient discharged on a CTO from the Fitzroy inpatient facility is being treated in the community by his or her private psychiatrist who practices in Lilydale. If the person subsequently relapses and needs inpatient treatment, admission will be to a bed in the Fitzroy inpatient facility.
  
  
• A patient living in Bendigo is referred by a general practitioner to Monash Medical Centre for medical treatment. The psychiatrist in the inpatient service at Monash should provide any required psychiatric services while the person is an inpatient at Monash. If following discharge they relapse and require inpatient psychiatric treatment (even if they require outpatient follow up for the medical condition at Monash), admission will be to a bed in the Bendigo mental health service.
  
  
• A person previously employed in a country town is moving to the metropolitan area to live with their parents. During the move they require inpatient treatment. The area mental health service responsible will be the area mental health service which covers the area where the person's parents live

Appendix 2: Child and Adolescent Services

Barwon South Western Region

Royal Children's Hospital Mental Health Service

Grampians Region

Royal Children's Hospital

Loddon Mallee Region

Royal Children's Hospital

Hume Region

Austin and Repatriation Medical Centre, Department of Child, Adolescent and Family Psychiatry

Gippsland Region

Monash Medical Centre

Western Metropolitan Region

Royal Children's Hospital Mental Health Service

Northern Metropolitan Region

Austin and Repatriation Medical Centre, Department of Child, Adolescent and Family Psychiatry

Eastern Metropolitan Region

Monash Medical Centre, Child and Adolescent Psychiatry Service

Southern Metropolitan Region

Monash Medical Centre, Child and Adolescent Psychiatry Service

Appendix 3: Aged Inpatient Services

Barwon South Western Region

Geelong Hospital and Grace McKellar Centre
Warrnambool and District Base Hospital

Grampians Region

Queen Elizabeth Centre

Loddon Mallee Region

Bendigo Healthcare Group
Goulburn Valley Base Hospital

Hume Region

Wangaratta District Base Hospital/Beechworth Hospital
Goulburn Valley Base Hospital

Gippsland Region

Latrobe Regional Hospital (Traralgon, Moe, old Hobson Park campuses)

Western Metropolitan Region

Western Healthcare Network (North-West Hospital)
Western Healthcare Network (Western Hospital)

Northern Metropolitan Region

Bundoora Extended Care Centre

Eastern Metropolitan Region

St Georges Hospital and Inner Eastern Geriatric Centre
The Peter James Centre
Alfred Healthcare Group

Southern Metropolitan Region

Dandenong Hospital
Kingston Centre
Mt Eliza Centre/Mornington Peninsula Hospital