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<pre>
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

South Australia Health 

Review of consumer flow across the 
mental health stepped system of care 
Final Report 
March 2015 

 
 
 

 

HEALTH AND HUMAN SERVICES 

GOVERNMENT ADVISORY SERVICES 



Review of consumer flow across the mental health stepped system of care 
 

Disclaimer 
 
Inherent Limitations 

This report has been prepared as outlined in the Scope Section.  The services provided in connection 
with this engagement comprise an advisory engagement which is not subject to Australian Auditing 
Standards or Australian Standards on Review or Assurance Engagements, and consequently no 
opinions or conclusions intended to convey assurance have been expressed.  

The findings in this report are based on a qualitative study and the reported results reflect a 
perception of SA Health but only to the extent of the sample surveyed, being SA Health approved 
representative sample of stakeholders.  Any projection to wider stakeholders is subject to the level 
of bias in the method of sample selection. 

No warranty of completeness, accuracy or reliability is given in relation to the statements and 
representations made by, and the information and documentation provided by, SA Health 
stakeholders consulted as part of the process. 

KPMG have indicated within this report the sources of the information provided.  We have not sought 
to independently verify those sources unless otherwise noted within the report. 

KPMG is under no obligation in any circumstance to update this report, in either oral or written form, 
for events occurring after the report has been issued in final form. 

The findings in this report have been formed on the above basis. 

Third Party Reliance 

This report is solely for the purpose set out in the Scope Section and for SA Health information, and 
is not to be used for any other purpose or distributed to any other party without KPMG s prior written 
consent. 

This report has been prepared at the request of SA Health in accordance with the terms of KPMG s 
engagement letter/contract dated 5 December 2014. Other than our responsibility to SA Health, 
neither KPMG nor any member or employee of KPMG undertakes responsibility arising in any way 
from reliance placed by a third party on this report.  Any reliance placed is that party s sole 
responsibility. 

 

 

i 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with 

KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 

Cooperative ("KPMG International"). 
Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 
 

Table of contents 

 

Glossary 1 

Executive Summary 2 

1. Context and background 6 

1.1 Context and reason for the review 6 

1.2 Scope and limitations 6 

1.3 Approach for the review 6 

2. The review 8 

2.1 Service trends/linked data analysis 8 

2.2 Medical record audit findings 19 

2.3 Stakeholder feedback 25 

3. Key findings 29 

3.1 Leadership and direction 29 

3.2 The model of care 29 

3.3 Demand and supply 31 

3.4 Service and outcome trends 31 

4. Recommendations 33 

4.1 On the horizon - What is needed longer term? 35 

4.2 Future considerations 35 

Appendix A : List of stakeholders consulted 36 

Appendix B : Stakeholder consultation guide 37 

Appendix C : Medical record audit tool 40 

Appendix D . Average length of stay by ward code 2011-12 to 2014-15 54 

 
 
 
 

ii 

 
  2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with 

KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 

Cooperative ("KPMG International"). 
Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

Glossary 

 

  
  
AIHW Australian Institute of Health and Welfare 
ALOS Average Length of Stay 
BAS Bed Allocation System 
CALHN Central Adelaide Local Health Network 
CMHS Community Mental Health Service 
CRC Community Rehabilitation Centre 
ED Emergency Department 
EICC Eastern Intermediate Care Centre 
FMC Flinders Medical Centre 
GLN Glenside 
HDU High Dependency Unit 
ICC Intermediate Care Centre 
LHN Local Health Network 
LMH Lyell McEwin Hospital 
MPH Modbury Public Hospital  
NALHN Northern Adelaide Local Health Network 
NEAT National Emergency Access Targets 
PICU Psychiatric Intensive Care Unit 
QEH Queen Elizabeth Hospital 
SALHN Southern Adelaide Local Health Network 
SECU Secure Extended Care Unit 
SICC Southern Intermediate Care Centre 
WICC Western Intermediate Care Centre 

 

 

1 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with 

KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 

Cooperative ("KPMG International"). 
Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

Executive Summary 

The review 

South Australia Health engaged KPMG to review the Metropolitan Adult Mental Health Service 
system in South Australia, with a focus on identifying blockages to consumer flow across the 
stepped model of care and developing recommendations to overcome these. The review occurred 
within the context of a number of previous evaluations and reviews of components or aspects of 
the SA mental health service system. Most recently a review of the Intermediate Care Services was 
completed in September 2013.  

Approach 

KPMG completed the review in March 2015 after conducting three principle activities: 

  a medical record file audit of 196 consumer files across a sample of all adult acute inpatient 
beds in metropolitan South Australia and the three Intermediate Care Centres using a 
structured clinical audit tool 

  consultation with over 20 key individuals such as Clinical Directors, Psychiatrists, Service 
Managers, Consumer and Carer representatives and Executives involved in the care and 
support of mental health consumers in South Australia 

  service data analysis, examining trends and key issues through the Emergency Department 
(ED), admitted and community mental health datasets including linkage across datasets to 
interrogate consumer flow challenges. 

Findings 

Some of the key issues identified through the review relate to critical service system processes and 
challenges associated with the way the  stepped model  of mental health care is working in 
practice. While there are significant and challenging issues identified the current review also 
provides a genuine opportunity to address these and implement longer term structural change 
and move South Australia s mental health service system forward in a sustainable way. 

It has been identified that mental health consumers are staying too long in emergency 
departments waiting for an acute adult inpatient bed. This issue has progressively worsened over 
the last four years with an average length of stay in ED for mental health consumers in 2013-14 of 
795 minutes or over 13 hours, and an average of 36 consumers staying longer than 24 hours in ED 
every week.   

Coupled with the challenges of increasing stays in ED for mental health consumers the acute 
inpatient unit length of stay has increased slightly over the same period to over 14 days. The 
increase in average length of stay in EDs has occurred despite recent increases in acute adult 
mental health bed numbers in South Australia. The introduction of Intermediate Care Centres, a 
centralised bed allocation system, integrated community mental health teams and a number of 
other changes aimed at improving and increasing the level of care provided in the community to 
mental health consumers do not appear to have made the impacts intended on the flow of 
consumers across the service system.  

2 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with 

KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 

Cooperative ("KPMG International"). 
Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

Findings from the medical record audit, service data analysis and stakeholder consultations 
illustrate issues of siloed service components, such as ED, inpatient units, ICCs and CMHS working 
for the most part in isolation with limited inreach or genuine communication and care planning 
between services occurring. While the centralised Bed Allocation System (BAS) was intended to 
improve transparency it appears to have increased decision time, become a largely administrative 
queue based system which has inadvertently reduced the level of ownership, accountability and 
responsibility of consumer flow at local levels. With decreased levels of local ownership noted 
during the review there is also confusion and debate about leadership and clinical governance 
across the South Australian metropolitan mental health service sector. This was seen at high levels 
but also at the point of care where a lack of leadership to address consumer flow was noted.   

At the individual consumer level the data analysis and file audits reveal significant issues associated 
with these system challenges. Consumers are not only staying for long periods in ED they are 
experiencing high rates of sedation and restraint, waiting for  medical clearance  and having 
multiple assessments with unclear outcomes other than  waiting for a bed . Consumers who could 
be safely managed in less restrictive community settings such as Intermediate Care Centres (ICCs) 
are commonly unable to be transferred or  stepped down  to these settings due to restrictive 
acceptance criteria. There seemed to be a lack of recognition of the clinical urgency to address the 
problem of prolonged ED stays for very disturbed consumers identified as needing a PICU or high 
support bed who are being kept in ED even when beds are available in the general areas of adult 
wards. Coupled with challenges in  bed based  services the community mental health services have 
limited interaction and are not involved directly in the decisions about which consumers can be 
safely managed in the community and which community referrals require inpatient care next.  

The default mechanism for access to the metropolitan mental health system has become the 
emergency departments, with a process of referral to the centralised BAS and the next consumer 
admitted is generally the person who has waited the longest in ED; creating a perverse incentive 
for mental health consumers who do not clinically require emergency department care to present 
there as a standard to access mental health inpatient care.  

Recommendations 

To address these findings the following recommendations have been developed to make 
immediate improvements for mental health consumers, while also considering the ongoing and 
future priority areas requiring change.  

The summary of recommendations of the review (contained in detail in section 4) are: 

1. No additional adult acute mental health inpatient beds are required at present, SA 
benchmarks well in terms of bed capacity. 

2. Clear responsibility for consumer outcomes is required, at present there is a lack of clear 
accountability and fragmented decision making. This should involve: 

a. Accountability for outcomes being placed at the Local Health Network (LHN) level 

b. Joint Clinical and Administrative oversight of the public mental health system 

c. Clear allocation of responsibilities between the clinical and administrative lead 

d. There should be a single clinical and administrative oversight of all elements of 
public mental health within each LHN: covering Community, ICC, inpatient and ED 

3 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with 

KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 

Cooperative ("KPMG International"). 
Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

3. Coupled with responsibility for outcomes, the clinical and administrative lead must also 
be given a clear allocation of resources to deliver and flexibility in the use of those 
resources: 

a. Each LHN should have a clear allocation of acute adult inpatient, ICC, and 
extended care beds and of community mental health resources. 

i. This will require some allocation of ICC beds to NALHN 

ii. This will also require an allocation of rehabilitation beds to each LHN 

b. The central Bed Allocation System which reduces the clarity of accountability for 
outcomes and can act as a disincentive to improve consumer flow should be 
removed.  

4. Revise the model of care for ICC beds. In the Longer term the model of care for ICC should 
be shifted to meet the post-acute needs of a broader cohort of consumers such that it:  

  places an emphasis on those who can be safely managed in the ICC environment 
rather than only accepting those consumers who are  low risk  

  considers implementing a range of medication management options for ICC 
consumers  

  shifts from requiring consumers to set their own goals to the shared identification 
of achievable goals for consumers who need step down from acute wards 

  allows use of the ICC stay to identify accommodation requirements 
  reflects a broader diagnostic cohort including those with more complex care 

needs. 

5. Establish a High level Statewide Mental Health Service Leadership group responsible to 
enact the following recommendations once endorsed.  

6. Promote leadership of mental health service delivery and consumer flow by: 
a. Re-establishing a sense of urgency and accountability for long inpatient lengths 

of stay to ensure that no mental health consumer stays in ED for longer than 24 
hours.  

b. Re-invigorating clear escalation plans to avoid consumers staying in the ED any 
longer than clinically required - within a 12-18 month period SA Health need to 
meet the Minister s targets and National Emergency Access Targets (NEAT) for 
mental health consumers presenting to ED. This will involve a whole of service 
approach to improving consumer flow matching capacity, via improved discharge 
planning and follow up, with current demand for acute beds. 

c. Increasing the linkages between the inpatient and community mental health  
d. Building staff competency in crisis/acute community management.  
e. Supporting the walk in centre model, or similar  walk in assessment/intake  

community based models providing options away from ED for people with acute 
mental health needs to present for assessment. 

f. Improving the transparency of decision making and access to extended care beds 
- allowing area clinical directors to prioritise the next consumer admitted and 
discharged for their area. 

g. Promoting awareness and education to health service staff about the 
inappropriateness of keeping consumers who require a PICU bed in ED.  

h. Refining central reporting and service indicators to enable ongoing evaluation at 
a whole of system level. 

4 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with 

KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 

Cooperative ("KPMG International"). 
Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

In conjunction with these recommendations a series of future considerations have also been 
provided for SA Health focussing on issues related to metropolitan adult mental health consumer 
flow that were beyond the direct scope of the current review. These considerations relate to 
population based bed modelling, detailed governance structure review and lean/redesign 
approaches for the mental health consumer journey.  

5 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with 

KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 

Cooperative ("KPMG International"). 
Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

1. Context and background 

KPMG was engaged by SA Health to conduct a review of key components of the Metropolitan Adult 
Mental Health Service system in South Australia in February 2015. The current report outlines the 
review approach, key findings and recommendations for SA Health. 

1.1 Context and reason for the review 
The ultimate objective of the review was to identify blockages to consumer flow 
across the stepped model of care and identifying recommendations aimed at 
resolving admission delays to acute mental health units and Intermediate Care 
Centre (ICC) beds from emergency departments. 

The review progressed within the context of a number of previous evaluations 
examining elements of the SA mental health care system. Specifically more recent reviews and 
reports have included: 

  Evaluation of the Intermediate Care Services, September 2013 (HOI) 

  Review of the South Australian Stepped System of Mental Health care and capacity to respond 
to emergency demand, July 2013 (EY) 

  Stepping Up: A Social Inclusion Action Plan for Mental Health Reform, 2007-2012, undated 
(South Australian Social Inclusion Board). 

While each of these reviews have provided recommendations and outlined a rationale for change 
in the delivery of Mental Health Services in South Australia, it is noted that there has been 
variability in the SA Health and Local Area Health Network response to each review and the 
application of the recommendations.  

1.2 Scope and limitations 
The scope of services reviewed included the total 241 Metropolitan Acute Adult Beds over eight 
sites and the total 45 Metropolitan Intermediate Adult Beds over three sites. The formal scope 
excluded Specialty Mental Health beds, Country LHN Mental Health beds and other bed types such 
as Secure Extended Care and Community Rehabilitation Centre beds. The scope also excluded 
detailed coverage of Community Mental Health Services. However where appropriate the critical 
interfaces and connections between the out of scope services and the in scope beds have been 
considered by the review in so far as these services facilitate or restrict movement from the 
Metropolitan Adult Acute Mental Health Service beds. 

1.3 Approach for the review 
The review consisted of three principle activities, including a medical record file audit, service data 
analysis and stakeholder consultation. The approach for each of these activities is outlined below. 

1.3.1 Medical record file audit 

KPMG developed a structured audit tool which was reviewed by the Project Steering Committee 
and rapidly trialled on a sample of records before being refined and used. For quality assurance 
purposes the tool was used by the KPMG team members and an Independent Consultant 

 

6 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with 

KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 

Cooperative ("KPMG International"). 
Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

Psychiatrist on the same records to calibrate the outputs and improve the reliability of findings 
between reviewers. A copy of the final medical record audit tool is provided in Appendix C. 

The purpose of the medical record file audit was to facilitate checking and reporting on areas such 
as: 

  clinical review decision points (time stamps from discharge decision to actual discharge) 

  Consultant and Registrar entries 

  discharge planning opportunities and identified barriers, including consideration of how early 
barriers to discharge are being actively identified 

  progress notes for evidence of discharge planning and progress towards discharge, including 
evidence of both  push  and  pull  efforts to support discharge. 

1.3.2 Service data analysis 

KPMG was provided with de-identified consumer level data records, for the last three full financial 
years and the year to date for the current financial year (2014-15), including de-identified 
statistical linkage keys to allow matching where possible across the following data sets: 

  Emergency Department presentation data 

  Acute Adult Inpatient data  

  Community Mental Health Service contact data. 

1.3.3 Stakeholder consultation 

KPMG developed a semi structured interview tool, which was reviewed by the Project Steering 
Committee members before being used to facilitate consistent discussions with key stakeholders 
involved with the management, clinical treatment and support of consumers in Metropolitan Adult 
Inpatient Mental Health beds in South Australia. A list of the stakeholders consulted during the 
review is included in the current report as Appendix A, along with a copy of the stakeholder 
consultation guide as Appendix B.  

 

 

 

7 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with 

KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 

Cooperative ("KPMG International"). 
Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

2. The review  

The following section provides an overview of high level service data trends, and 
a summary of the key qualitative and quantitative data issues highlighted 
through the conduct of the medical record file audits and stakeholder 
consultation.  

2.1 Service trends/linked data analysis 
Key observations from the service data analysis are: 

  There has been an approximately seven per cent increase in mental health related ED 
presentations between 2011-12 and 2013-14 to a total of 14,278 in 2013-14. 

  The vast majority of all adult acute inpatient admissions present via ED (87 per cent of all 
presentations were admitted via ED or transferred from another hospital), highlighting limited 
direct/community access. 

  For acute mental health consumers presenting to ED there is an increasing length of stay in ED 
with a deterioration year on year 

  There was a significant change in practice at Glenside inpatient units during the last four 
financial years, influencing the overall average length of inpatient stay for mental health 
consumers. When ALOS is analysed across all adult acute inpatient units (excluding Glenside) 
the trend appears to be increasing from 13.2 days in 2011-12 to 14.8 in 2014-15. 

2.1.1 System level consumer flow 

Overall flow of mental health consumers across ED and inpatient settings highlights a growing 
challenge for the system in the 2013-14 financial year with more admissions to inpatient units 
coming from ED than any other referral source (2,780 separations). This compares with direct 
community referrals of 274 from community health and 364 from outpatient departments.  

The pathway for the standard referrals has become one of admission through the emergency 
department. With 4,415 referrals for inpatient admission presenting either via ED or transferred 
from another hospital, these pathways are considerably more common than direct community 
admission or 87 per cent of all admissions (identified with a known referral source).  

The Figure 1 below provides key system level data for 2013-14. These data show  

 

 

 

 

 

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   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with 

KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 

Cooperative ("KPMG International"). 
Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

Figure 1: Mental Health related summary statistics for 2013-141 

 
Source: KPMG analysis of service data provided by Information Management Data and Reporting 
Services, and Mental Health and Substance Abuse Unit both part of System Performance SA Health, 
February 2015 

While there is consistent feedback from stakeholders in metropolitan South Australia Mental 
Health Services about having less beds currently than was the case a number of years earlier the 
bed data does not support this. In summary the adult acute mental health bed stock for 
metropolitan SA has increased over the last eight years (see Table 1 below), there has been 
localised changes that have meant that the bed changes have not been experienced evenly across 
local areas. As an example over the same period beds at The Queen Elizabeth Hospital have 
decreased from 31 to 21 beds while others such as Lyell McEwin Hospital (1G) has increased from 
20 to 26 beds, with the addition of 4 short stay beds also.    

Table 1: SA Metropolitan adult acute mental health beds 2007-2015  

Beds Wards or Units  2007-08 2010-11 2011-12 Mar-14 Feb-15 

Total Adult Acute (excluding 
ICC beds) 243 253 243 235 267 

Percent change on previous 
period n/a 4.1% -4.0% -3.3% 13.6% 

Source: Bed data supplied by Mental Health and Substance Abuse Unit, Systems Performance, SA 
Health, February 2015 

 

1 KPMG analysis based on data supplied by SA Health, including ED, acute inpatient, ICC and CBIS data. 

Emergency Department
Presents: 14,278
Unique Patients: 10,661
Average time in ED: 795 
minutes

Inpatient
Separations: 5,272
Unique Patients: 3,867
ALOS: 14.1 days

Mental health related summary statistics for 2013/14 

Summary 
statistics

Patient arrived 
from
ED Arrival mode
IP Source of 
Referral

Patient went to
ED Departure status
IP Nature of 
separation

Presents by arrival mode 
Ambulance: 6,924
Walk in: 2,485
Other: 1,953
Private care: 1,703
Police vehicle: 876

Separations by Referral 
source
Casualty/Emergency: 2,780
Inter Hosp. Transfer: 1,736
Other: 971
Outpatient Dept.: 364
Community Health: 274

Presents by departure 
status
Home: 8,611
Admission to ward: 3,453
Admission to EECU: 989
Transfer other hosp.: 557
Admission within ED: 271

Separations by nature 
separation 
Home: 4,580
Hosp. Down Transfer: 506
Other Health Care: 451
Hosp. Up Transfer: 443
RACF: 161

ICC discharges
Unique episodes: 1,181
Unique clients: 926
Average days between 
start and end per episode: 
9.8 days
Median days between start 
and end per episode: 9
days

Community
Contacts: 5,395
Unique episodes: 1,310 
Unique clients: 1,045
Average contacts per 
episode: 4.3 

Note: These summary 
statistics for ICC and 
Community contacts are 
where the episode type 
(epitype) is classified as 
CR.

9 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with 

KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 

Cooperative ("KPMG International"). 
Liability limited by a scheme approved under Professional Standards Legislation. 

 

                                                             
 



Review of consumer flow across the mental health stepped system of care 
 

2.1.2 Emergency Department presentations 

Some of the key issues highlighted through the ED data analysis are: 

  One in ten ED presentations in 2013-14 were longer than 36 hours.  

  1,892 mental health consumers presenting to EDs in 2013-14 stayed over 24 
hours. This represents 36 mental health consumers staying longer than a day in 
ED every week of the year. 

  Time in ED is increasing across financial years and all triage categories. Average time is 
greater than 10 hours, median is greater than five hours.  

  There is substantial variation in time in ED by Departure status. When consumers are admitted 
to ward within the hospital the average wait time is 1,642 minutes (approximately 27 hours) 
and 2,280 minutes (approximately 38 hours) when transferred to another hospital. 

  Ambulance arrivals for mental health consumers presenting to ED were the most common (48 
per cent of all presentations), while Police presentations were noted as  common  by 
stakeholders they represented a much lower proportion at six per cent of the total. 

By financial year 

Mental health related ED presentations increased by 6.5 per cent between 2011-12 and 2012-13 
and only increased by 0.5 per cent (i.e. almost no change) between 2012-13 and 2013-14. Based 
on the four months to date this financial year the trend appears to be an increasing one for 2014-15 
with 8 per cent more presentations for July to October 2014-15 than for the same four month 
period in 2013-14.  In comparison to all ED presentations the growth in mental health related 
presentations was similar between 2011-12 and 2012-13 and slightly lower between 2012/13 and 
2013-14 (see Table 2 below). 

Table 2. ED Mental health related presentations and total presentations by financial year with per 
cent growth on previous financial year in brackets 

Year 2011/12 2012/13 2013/14 2014/15 (YTD) 
Mental health 
presentations 

13,341 14,211 (6.5%) 14,278 (0.5%) 4,978 

Total 
presentations 

427,011 455,220 (6.6%) 463,171 (1.7%) N/A 

Source: Data supplied by SA Health and from Australian Institute of Health and Welfare 2014. 
Australian hospital statistics 2013 14: emergency department care. Health services series no. 58. Cat. 
no. HSE 153. Canberra: AIHW. 

By financial year and hospital 

The majority of emergency department presentations for mental health consumers follow the 
overall trend of steady increase, the exceptions being FMC and Noarlunga where there appears to 
have been a shift of activity from Noarlunga (358 consumers less 2011-12 to 2013-14) to FMC (526 
more consumers 2011-12 to 2013-14). These annual presentation changes are shown by 
presenting hospital emergency department in Table 3 below. The rate of presentation for mental 
health consumers to metropolitan EDs in 2013-14 reflects an average of 40 presentations across 

 

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Review of consumer flow across the mental health stepped system of care 
 

all EDs per day. The RAH has the equivalent of 12.6 presentations per day, experiencing the highest 
volume of all EDs. 

Table 3. ED Mental health related presentations by financial year and hospital 

Hospital 2011/12 2012/13 2013/14 2014/15 
(YTD) 

FMC 2,180 2,601 2,706 907 
LMH 2,173 2,280 2,342 907 
Modbury 639 633 694 314 

Noarlunga 1,776 1,771 1,418 506 
RAH 4,233 4,454 4,507 1,487 
TQEH 1,822 1,913 1,969 636 
WCH-Paediatrics 518 559 642 221 
Total presentations 13,341 14,211 14,278 4,978 

Source: Information Management Data and Reporting Services, System Performance, SA Health, 
February 2015 

By financial year and diagnosis description 

The presentations of mental health consumers to EDs has remained similar across all years 
analysed with alcohol related presentations the most common diagnosis for past three full 
financial years, closely followed by adjustment disorders. One diagnostic group that has increased 
during the period has been anxiety related presentations with a 53 per cent increase between 
2011-12 and 2013-14. 

The top five diagnosis descriptions for 2013/14 are presented in the table below, which have 
generally been the top five diagnoses descriptions over the period. These presentation figures by 
diagnosis reinforce the need for holistic responses and strong collaboration between mental 
health and drug and alcohol services within the ED environment.  

Table 4. ED Mental health related presentations by financial year and diagnosis description 

Diagnosis description 2011/12 2012/13 2013/14 2014/15 
(YTD) 

Ment &amp; beh disrd dt alcohol use ac intox 2,453 2,664 2,488 882 

Adjustment disorders 2,197 2,457 2,337 849 

Schizophrenia unspecified 988 955 844 317 

Anxiety disorder unspecified 548 670 836 247 

Depres ep not in the postnatal period 568 590 595 182 

Source: Information Management Data and Reporting Services, System Performance, SA Health, 
February 2015 

By financial year and hour of presentation 

Mental health related ED presentations by hour of day are remarkably consistent across financial 
years and not unlike trends seen in other jurisdictions. Presentations peak in the late afternoon (4 
to 5pm) and remain relatively high between 11am through to 1am with a low point in the early 

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Review of consumer flow across the mental health stepped system of care 
 

morning (6 to 8am). These presentation patterns reinforce the need for strong after hours service 
cover and access to inpatient beds and discharge support 24 hours a day. Figure 2 below illustrates 
the mental health related presentation trends by financial year and hour of day. 

Figure 2. ED Mental health related presentations by financial year and hour of presentation 

 
 

The volume of ED mental health related presentations in 2013/14 varied substantially by hour. The 
 peak hour  for ED mental health related presentations in 2013/14 was 4.00pm to 4.59pm (1600 
to 1659) with 868 presentations. In contrast for the period 7.00am to 7.59am there were 152 
presentations. The average length of time in ED was generally highest in traditional core business 
hours (i.e. 9.00am to 5.00pm). Presentations and average length of stay are outlined in the figure 
below. 

Figure 3. ED Mental health related presentations for 2013/14 by hour of presentation and average 
time in ED for that hour 

 
Source: Information Management Data and Reporting Services, System Performance, SA Health, 
February 2015 

0
100
200
300
400
500
600
700
800
900

1000

00
00

 to
 0

05
9

01
00

 to
 0

15
9

02
00

 to
 0

25
9

03
00

 to
 0

35
9

04
00

 to
 0

45
9

05
00

 to
 0

55
9

06
00

 to
 0

65
9

07
00

 to
 0

75
9

08
00

 to
 0

85
9

09
00

 to
 0

95
9

10
00

 to
 1

05
9

11
00

 to
 1

15
9

12
00

 to
 1

25
9

13
00

 to
 1

35
9

14
00

 to
 1

45
9

15
00

 to
 1

55
9

16
00

 to
 1

65
9

17
00

 to
 1

75
9

18
00

 to
 1

85
9

19
00

 to
 1

95
9

20
00

 to
 2

05
9

21
00

 to
 2

15
9

22
00

 to
 2

25
9

23
00

 to
 2

35
9

2011/12 2012/13 2013/14

0

200

400

600

800

1,000

1,200

0
100
200
300
400
500
600
700
800
900

1,000

00
00

 to
 0

05
9

01
00

 to
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15
9

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00

 to
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25
9

03
00

 to
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35
9

04
00

 to
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45
9

05
00

 to
 0

55
9

06
00

 to
 0

65
9

07
00

 to
 0

75
9

08
00

 to
 0

85
9

09
00

 to
 0

95
9

10
00

 to
 1

05
9

11
00

 to
 1

15
9

12
00

 to
 1

25
9

13
00

 to
 1

35
9

14
00

 to
 1

45
9

15
00

 to
 1

55
9

16
00

 to
 1

65
9

17
00

 to
 1

75
9

18
00

 to
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85
9

19
00

 to
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95
9

20
00

 to
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05
9

21
00

 to
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15
9

22
00

 to
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25
9

23
00

 to
 2

35
9

M
inutes

M
en

ta
l h

ea
lth

 p
re

se
nt

at
io

ns

Presents Average time Median time

12 
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Review of consumer flow across the mental health stepped system of care 
 

The volume of ED mental health related presentations in 2013/14 did not vary greatly by day of 
week. The peak day for presentations in 2013/14 was Sunday with 2,181 presentations while 
Friday has the lowest number of presentations with 1,975 presentations. As seen in Figure 4 below 
the average and median time in ED was lowest on Sundays, even though this was the day of the 
week with the highest number of mental health related presentations. 

Figure 4. ED Mental health related presentations for 2013/14 by day of week and average and 
median time in ED for that day 

 
Source: Information Management Data and Reporting Services, System Performance, SA Health, 
February 2015 
When analysing mental health related ED presentations across the period the age distribution is 
remarkably consistent across financial years across all age bands from 16 to 65.  

By financial year and arrival mode 

The majority of mental health consumers presenting to ED arrive via ambulance, with the next 
largest category being  walk in . Of note the increase in ED presentations over the 2011-12 to 2014-
15 period appear to relate largely to an increase in ambulance presentations with approximately 
a 12 per cent increase over the last three full financial years. 

Table 5. ED Mental health related presentations by financial year and arrival mode 

Year 2011/12 2012/13 2013/14 2014/15 
(YTD) 

Ambulance Service 6,184 6,585 6,924 2,453 

Walk in 2,331 2,456 2,485 806 

Other 1,712 1,953 2,036 696 

Private car 2,027 1,993 1,703 545 

Police Vehicle 877 991 876 399 

Community/Public Tran 117 124 114 42 

Taxi 75 84 103 31 

0
100
200
300
400
500
600
700
800
900
1000

0

500

1,000

1,500

2,000

2,500

M
on

da
y

Tu
es

da
y

W
ed

ne
sd

ay

Th
ur

sd
ay

Fr
id

ay

Sa
tu

rd
ay

Su
nd

ay

M
inutes

M
en

ta
l h

ea
lth

 p
re

se
nt

at
io

ns

Presents Average time Median time

13 
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Review of consumer flow across the mental health stepped system of care 
 

Year 2011/12 2012/13 2013/14 2014/15 
(YTD) 

Air Ambulance 9 9 18 1 

Unknown/Not Stated . 2 13 4 

Volunteer transport 4 12 6 1 

Helicopter 5 2 . . 

Total 13,341 14,211 14,278 4,978 

Source: Information Management Data and Reporting Services, System Performance, SA Health, 
February 2015 

By financial year and departure status (i.e. Episode complete-Home, 
Admission to ward, Admission within ED) 

The majority (60 per cent or 8,611 in 2013-14) of mental health related ED presentations depart 
home.   

Table 6. ED Mental health related presentations by financial year and departure status 

Year 2011/12 2012/13 2013/14 2014/15 
(YTD) 

Episode complete-Home 7599 8637 8611 2991 

Admission to ward 3087 3164 3453 1237 

Admit to EECU 1241 1038 989 310 

Transfer out of this hospital to another 666 731 557 207 

Admission within ED 313 254 271 105 

Left at own risk after treatment started 287 264 237 87 

Episode complete-Other 77 59 66 21 

Did Not Wait to be seen (DNW) 42 38 55 16 

Not Stated/Unknown 29 26 39 4 

Source: Information Management Data and Reporting Services, System Performance, SA Health, 
February 2015 

By financial year and time in ED 

The average and median time in ED has increased between 2011/12 and 2013/14 financial years2.  
The percentiles provide a sense of the shape of the distribution of time spent in ED for mental 
health presentations. The P90 value (90th percentile) for 2013/14 was 2,162 minutes 
(approximately 36 hours or 1.5 days). This can also be interpreted as there were 10 per cent of 
presentations (or 1,427 presentations) that were longer than 1.5 days. 

2 Time in the emergency department was calculated by subtracting the presentation date and time from the 
departure date and time 

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Review of consumer flow across the mental health stepped system of care 
 

There is substantial variation in time spent in ED by departure status. When consumers are 
admitted to ward within the hospital the average wait time is 1,642 minutes (approximately 27 
hours) and 2,280 minutes (approximately 38 hours) when transferred to another hospital. 

Table 7. Time spent in ED in minutes by FY 

Year Count 
presentations 

Average time 
minutes 

Median time 
minutes 

P10 minutes P90 minutes 

2011/12 13,341 613 295 93 1,492 
2012/13 14,211 678 311 99 1,594 
2013/14 14,278 795 320 102 2,162 
2014/15 
(YTD) 

4,978 947 336.5 
104 2,751 

Source: Information Management Data and Reporting Services, System Performance, SA Health, 
February 2015 
The following figure highlights the increasing trend in average length of stay (ALOS) for mental 
health consumers presenting to EDs across years and illustrates the longer stay consumers are 
increasing overall.  

Figure 5. Time spent in ED in minutes by FY including the 10th and 90th percentiles 

 
Source: Information Management Data and Reporting Services, System Performance, SA Health, 
February 2015 
The average time spent in ED for mental health consumers is increasing each year across all triage 
categories as illustrated in Figure 6 below. These data highlight the increasing length of stay in ED 
does not appear related to a particular acuity or particular cohort of mental health consumers. 

0

500

1,000

1,500

2,000

2,500

3,000

2011/12 2012/13 2013/14 2014/15

M
in

ut
es

Average time minutes P10 minutes P90 minutes

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Review of consumer flow across the mental health stepped system of care 
 

Figure 6.Time spent in ED in minutes by FY and triage category 

 

Source: Information Management Data and Reporting Services, System Performance, SA Health, 
February 2015 

2.1.3 Adult acute inpatient admissions 

When analysing the average length of stay in metropolitan acute adult mental 
health inpatient units it became clear that a significant change in practice and 
bed numbers at Glenside was influencing overall ALOS trends. For this reason 
ALOS tends have been analysed both including and excluding Glenside to show 
a clearer picture of the trend across years. A detailed breakdown of ALOS trends 

by adult acute mental health ward code is provided in Appendix D.  

When ALOS trends are compared across the period 2011-12 to 2014-15 (excluding Glenside) there 
appears to have been a slight increase from 13.2 days in 2011-12 to 14.8 days in 2014-15. 

Table 8. Separations, consumers and length of stay statistics by financial year (includes Glenside) 

FY Separations Unique 
consumers 

Length of 
stay 

Separations per 
consumer 

ALOS per 
separation 

2011/12 7,362 5,314 154,141 1.4 20.9 
2012/13 6,418 4,564 112,693 1.4 17.6 
2013/14 6,414 4,604 94,575 1.4 14.7 

2014/15 2,157 1,724 31,339 1.3 14.5 

Source: Mental Health and Substance Abuse Unit, System Performance SA Health, February 2015 
  

0

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Tr
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ge
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 5

2011/12 2012/13 2013/14 2014/15

M
in

ut
es

 
 

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Review of consumer flow across the mental health stepped system of care 
 

Table 9. Separations, consumers and length of stay statistics by financial year (excludes Glenside) 

FY Separations Unique 
consumers 

Length of 
stay 

Separations per 
consumer 

ALOS per 
separation 

2011/12 5,874 4,384 77,454 1.3 13.2 
2012/13 5,231 3,775 72,842 1.4 13.9 
2013/14 5,272 3,867 74,430 1.4 14.1 
2014/15 1,761 1,473 26,028 1.2 14.8 

Source: Mental Health and Substance Abuse Unit, System Performance SA Health, February 2015 
As seen in Figure 7 below the three main days of separation for mental health inpatients are 
Monday, Wednesday and Friday. In total 90.1 per cent of separations are on weekdays and 9.9 per 
cent of separations are on weekends. This highlights the challenges for admissions on the 
weekend. 

Figure 7. Separations and percentage of all separations by day of week for 2013/14 

 
Source: Mental Health and Substance Abuse Unit, System Performance SA Health, February 2015 
In 2013/14 there were 647 unique consumers that had multiple complete episodes that were not 
same day episodes. For example one consumer had three separations in 2013/14, with the 
following admission and separation dates 

1. Admission on 1st of January and separation on 2nd of January  

2. Admission on 17th of March and separation on 26th of March 

3. Admission on 27th of March and separation on 31st of March 

This consumer would be classified as having an unplanned readmission i.e. readmission within 28 
days due to the separation on the 26th of March and admission on the 27th of March being less 
than 28 days apart. There were 313 of these 647 consumers that had multiple episodes with 
separation dates and subsequent admission dates within 28 days. This equates to approximately 
7.2 per cent of all unique consumers (4,383) in 2013/14 experiencing a readmission within 28 days. 

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

0

200

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1,400

1,600

Percentage separations

Se
pa

ra
tio

ns

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Review of consumer flow across the mental health stepped system of care 
 

These figures appear low when compared with other jurisdictions. Note that, due to time 
constraints, this analysis does not include episodes that occur across financial years. 

2.1.4 ICC admissions 

There were four separate ICC discharge files supplied. The four files were for each of the financial 
years from 2011/12 through to 2014/15 (year to date). The files had names such as  ip and icc 
discharges 2014_15 20141224_1_enc.xlsx.  The limited timeframe available to undertake analysis 
of this data and the absence of a data dictionary to aid in the interpretation of the supplied data 
limited the extent of the analysis and data linkage that could be undertaken. Analytical results 
presented below should be subsequently viewed with caution. 

Table 10 below presents the count of episodes, unique clients and total length of stay for those 
episode types classified as  CR.0000.  Between 2012/13 and 2013/14 the number of episode, 
clients and average length of stay has remained similar.  

Table 10. Episodes, clients and total and average length of stay for ICC admissions by financial 
year 

FY 2011/12 2012/13 2013/14 2014/15 (YTD) 
Episodes 761 1,174 1,181 416 
Unique clients 618 911 926 379 

Total length of stay 8,240 11,128 11,596 4,291 
ALOS per episode 10.8 9.5 9.8 10.3 

Source: Mental Health and Substance Abuse Unit, System Performance SA Health, February 2015 
While detailed linked data analysis was not able to be conducted across the ED, acute inpatient 
and ICC data sets; it is clear that if the ICC beds purpose was in part to reduce the length of stay 
for consumers in ED or inpatient settings this has not occurred. Over the past four years there has 
been an increase in the ED LOS for mental health consumers and an increase in the acute adult 
LOS (excluding Glenside beds), with the addition of the ICC bed stay of approximately 10 days on 
average across the same period. 

2.1.5 Community Mental Health contacts 

Table 11 below presents the count of episodes, unique clients and total contacts for those episode 
types classified as  CR.0000.  Between 2012/13 and 2013/14 the number of episode, clients and 
average length of episode has remained similar.  

Table 11. Episodes, clients and total and contacts for ICC contacts by financial year 

FY 2011/12 2012/13 2013/14 2014/15 (YTD) 
Episodes 781 1,272 1,310 468 
Unique clients 640 1,003 1,045 424 

Contacts 3,631 5,262 5,395 1,942 

Source: Mental Health and Substance Abuse Unit, System Performance SA Health, February 2015 
 

 

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Review of consumer flow across the mental health stepped system of care 
 

2.2 Medical record audit findings 
The key themes emerging from the medical record audit reflect the findings 
from the stakeholder interviews. In summary these are: 

  Multiple reviews in ED, in addition to waits for medical clearance and/or 
extended periods of observation 

  Sedation and restraint was not uncommon practice in the ED 

  High rates of involuntary treatment order usage, frequently 
commencing in the ED 

  Delays in transferring consumers to an acute mental health bed, with limited evidence of the 
use of escalation strategies 

  Limited discharge planning occurring on admission to a ward  

  Limited consumer and carer input into care planning (with the exception of the ICCs) 

  Limited inreach or communication with CMHS teams 

  Limited completion and transmission of discharge summaries within 24 hours. 

2.2.1 Overall file review findings 

A total of 197 consumer files were reviewed. Figure 8 shows that the majority of consumer files 
were from FMC. 

Figure 8: The number of consumer files audited by health service. 

 
Source: KPMG medical record audit, February 2015 

 

Within the sample of medical records audited the average age of all consumers was 43. The 
youngest consumer was 15, the oldest was 79 (with a standard deviation of 14.5 years).  

Overall, 64 per cent of consumers were involuntary for all or part of their admission, however this 
varied between service settings, with only one ICC consumer across three sites being noted as 

7

35

22
24

19 19 19

14

24

7 7

0

5

10

15

20

25

30

35

40

Patient Count

 

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Review of consumer flow across the mental health stepped system of care 
 

involuntary. This is highlighted in Figure 9 below.  It was noted that a high proportion of consumers 
completed treatment orders whilst in the Emergency Department.   

Figure 9: The involuntary status of all consumers. 

 
Source: KPMG medical record audit, February 2015 

 

Overall, 31 per cent of consumers were new to the health service. Almost all consumers within the 
ICCs were consumers known to the service, illustrate in Figure 10 below. The Glenside Inpatient 
Unit had the highest proportion of  new  consumers with only a third of consumers previously 
known to the service.  

Figure 10: New consumer to the service proportion. 

 
Source: KPMG medical record audit, February 2015 

 

100%

26% 27% 17%
29%

11% 6% 14%

91% 86%
100%

36%

74% 73% 83%
71%

89% 94% 86%

9% 14%

64%

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%

100%

Involuntary Status

No Yes

100%
74%

33%

83% 72%
56% 47% 57%

91% 100% 86%
69%

26%

67%

17% 28%
44% 53% 43%

9% 14%
31%

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%

100%

New Consumer to Service

No Yes

20 
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Review of consumer flow across the mental health stepped system of care 
 

2.2.2 Emergency Department   file review findings 

Of the 197 files reviewed, 80 (41%) involved an emergency department stay; however due to the 
disparate nature of medical records for inpatient and ED this is a potential underestimate, with 
some file admission information unclear as to whether or not the consumer presented via ED 
before entry to the inpatient unit.  

Figure 11 below shows that:  

  88 per cent of files reviewed showed evidence that the consumer was assessed for mental 
illness.  

  80 per cent of files reviewed showed evidence that the consumer was referred to a mental 
health team or service.  

  88 per cent of files reviewed showed evidence of senior medical officer input or review.  

  75 per cent of files reviewed showed evidence of use of a mental health risk assessment tool.  

  48 per cent of files reviewed showed evidence of discharge or transfer planning to a mental 
health unit.  

  Discharge or transfer delays were not noted in 46% of emergency department cases. 

Whilst a relatively high percentage of consumers were assessed for mental illness, there was 
variable use of standardised tools at this part of the process. There was limited evidence of 
discharge or transfer planning to a mental health unit and delays were noted in almost half of the 
medical records audited.  

Reasons for delays included waiting for a bed, extended observation requirements and awaiting 
medical clearance. It was noted that a number of consumers were restrained or sedated during 
these periods. Waiting for a bed was the most common reason, however, there was minimal 
documentation detailing how this was being addressed. 

 

 
 

File audit note   ED consultant note  the patient (your consumer) needs to be transferred to a 
mental health bed has been  medically cleared  not appropriate for continued management 
in ED  

 

File audit note - At initial point of delay   ED staff discussed with after-hours nursing manager 
who queried  bed swap the next morning as cannot do it at night . Consumer remained in ED 

overnight and listed for HDU. Daily review by Psych medical officers, remained in for three days. 

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Review of consumer flow across the mental health stepped system of care 
 

Figure 11: Key emergency department file audit statistics. 

 
Source: KPMG medical record audit, February 2015 

2.2.3 Admission to Acute Inpatient/ICC Bed   file review findings 

Key findings noted from the medical record file audit of acute inpatient admissions are discussed 
below.  

In general assessment, diagnosis treatment planning, and implementation of that plan was seen 
consistently in the files. However only: 

  28 per cent showed evidence of any discharge planning at time of admission.  

  40 per cent of files showed evidence of identification of potential barriers to discharge or 
transfer noted in the medical record. 

  25 per cent of files showed evidence of Community Mental Health Service inreach at any time 
pre-discharge. 

  39 per cent of files showed evidence of discharge summary transmission within 24 hours of 
discharge. 

 

 

 

6%

15%

13%

23%

48%

46%

6%

5%

5%

3%

5%

9%

88%

95%

80%

88%

75%

48%

31% 14%

0 10 20 30 40 50 60 70 80

Evidence of assessment of consumer for mental illness

Evidence of a diagnosis of mental illness

Evidence of referral to mental health team/service/unit

Evidence of senior medical officer input/review

Use of mental health risk assessment tools

Discharge or transfer planning to mental health unit/bed

Discharge/transfer delays noted

Emergency Department Measures

No Partial Yes (blank)

File audit note - Request for Admission submitted Monday 23:00 admitted to ward Thursday 
1:55. Plan for acute bed noted but no indication of delays. 

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Review of consumer flow across the mental health stepped system of care 
 

The following figure provides a breakdown of differences in discharge planning during initial 
assessment across inpatient acute units and ICCs. This illustrates the variation in approach to 
discharge planning between services and a focus on assessment and treatment at the beginning 
of the inpatient episode. 

Figure 12: Evidence of discharge planning by health service. 

 
Source: KPMG medical record audit, February 2015 

 

 
 

Similar to discharge planning processes there was variation in how consumers were involved in 
their own care planning across services, as highlighted in Figure 13 below. Consumer care planning 
was more commonly documented in the ICC setting. 

29%, 2

54%, 19

95%, 21

48%, 11

16%, 3

68%, 13

37%, 7

62%, 8
71%, 17

86%, 6

14%, 1

33%, 4

22%, 11

4%, 1

34%, 9

12%, 3

32%, 10
27%, 5

19%, 6
11%, 1

30%, 4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Evidence of discharge planning during initial consumer 
assessment

N/A No Partial Yes

File audit note - Discharge planning first mentioned on admission however family meeting and 
eventual plan took three and a half weeks. 

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Review of consumer flow across the mental health stepped system of care 
 

Figure 13: Evidence of consumer involvement in care planning. 

 
 Source: KPMG medical record audit, February 2015 

 

Similar to consumer involvement in care planning there was a high degree of variation between 
services regarding the involvement of carers in care planning. Overall the rate of involvement was 
lower again with less than half observably involved. 

 

The file audit highlighted limited CMHS in reach occurring in most services with the exception of 
two of the ICCs where there appeared to be more proactive CMHS involvement, as illustrated in 
Figure 14 below. In the majority of cases, referrals to CMHS were made at the point of discharge; 
there was little evidence to suggest that CMHS in reach occurred in the acute setting. 

23%, 8
13%, 3

11%, 2
5%, 1

31%, 4

13%, 3 14%, 1

71%, 5
63%, 22

91%, 20

61%, 14

37%, 7

84%, 16
100%, 19

62%, 8
74%, 17

100%, 7

29%, 2

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Evidence of consumer involvement in care planning

N/A No Partial Yes

File audit note - Brother quoted as saying he was  not aware of consumer's plan to stay with 
 

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Review of consumer flow across the mental health stepped system of care 
 

Figure 14: Evidence of Community Mental Health Service inreach pre-discharge. 

 
Source: KPMG medical record audit, February 2015 

 

A similar pattern was observed when examining the consumer files for evidence of discharge 
summary transmission within 24 hours, all three ICCs appeared to process these in a timely manner 
as standard practice however this was not the case for inpatient settings. In total the number of 
discharge summaries sent within 24 hours was 39 per cent, including electronic and manual 
systems.  

2.3 Stakeholder feedback 
Several consistent themes emerged from the review consultation that were 
reinforced by a number of different stakeholder groups. Broadly these themes 
related to the following: 

  Access to inpatient beds and ICC beds is challenging for consumers and 
carers, mental health clinicians in inpatient settings, mental health clinicians in 
community settings and clinicians in emergency departments. Many senior 
stakeholders reported the process for access as  opaque ,  unclear  and 
 misaligned  with clinical need or acuity.  

  Clinical governance structures and processes are not assisting clinicians to admit, discharge 
or transfer consumers to the most appropriate care settings. Reports of having to refer a 
consumer who was in ED to the centralised bed allocation (BAS) system, consultant 
psychiatrists, psychiatric registrars and service managers with no clear outcome other than to 
 wait  was reinforced by the majority of stakeholders.  

29%, 2

77%, 27
76%, 16

70%, 16
89%, 17

63%, 12
74%, 14 69%, 9

54%, 13
71%, 5

29%, 2

57%, 4

17%, 6 24%, 5 17%, 4

37%, 7
26%, 5 31%, 4 29%, 7 29%, 2

71%, 5

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Evidence of Community Mental Health Service inreach 
pre-discharge

N/A No Partial Yes

 

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Review of consumer flow across the mental health stepped system of care 
 

  Delays to acute inpatient admissions are now  the norm  with consumers often waiting in 
ED for extended periods. Commonly these delays are creating significant challenges and issues 
for the appropriate care and management of acutely unwell mental health consumers in the 
ED. Stakeholders reported increasing rates of sedation and restraint being used, due to a lack 
of alternative management options. A number of stakeholders described this trend as a 
 hidden statistic  with reporting of restraint often only captured in the clinical notes for ED. 
Another directly related challenge both ED and Mental Health stakeholders reported was the 
 increasing use of  specials  in ED .   

  Referral and access to Secure Extended Care Unit beds is difficult and unclear. There is a 
standard form for referral and a  panel  who meets to decide who the next consumer admitted 
to beds will be, this system was described as  unclear  and  opaque  with the outcome of the 
referral often non acceptance of the consumer with a  vague  rationale. Many referrers said 
they now refer  rarely if at all  for these reasons. 

  Siloed units and services were commonly described as creating  barriers  to access rather 
than facilitating referrals. A number of senior stakeholders including clinical directors and 
managers noted access to some services appeared to be coming  more complicated and varied 
depending on who takes the referral . An example provided illustrates this point; a staff 
member referred a voluntary consumer to an ICC bed who was  taken off an ITO  12 hours 
earlier but was told they needed to be off ITO for a period of 24 hours prior to acceptance, 
 this was not the case  months earlier.  

  Permission to admit  blue dot patients  into three of the 15 Southern ICC beds is allowing 
appropriate step down from inpatient beds for consumers who did not  clinically require  an 
acute bed but were  stuck there  due to other reasons such as  homelessness ; which was a 
previous barrier for ICC bed acceptance.   

  Centralised bed management is not working as intended. The vast majority of stakeholders 
described the process of referral to an administrative staff member as a  passive  and  one 
way  step, with  frustration  over the system outcomes of what has largely become an 
 administrative queuing system  where  those waiting in ED the longest get the next acute 
bed . While there is opportunity to review  clinical risk and urgency  this was standardly 
covered once a day in a morning teleconference or on an ad hoc basis, when clinical leaders  
contacted the BAS staff to elevate the urgency of certain consumers referred.  

  Access to PICU and HDU beds is an issue because of low turnover. While stakeholders 
reported the reason for keeping consumers in ED was limited  locked bed  availability, they 
reported there was not a perceived  urgency  for more regularly reviewing consumers in 
HDU/PICU who could be appropriately stepped down to an open bed.  

  In-reach from Community Mental Health Services is not occurring. All stakeholders identified 
this was a process that was happening as the  exception rather than the rule  and if it did 
occur it was often  on the day of discharge . There were exceptions to this process such as the 
Central/Eastern CMH Service having two team members attend the hospital, though it was 
noted this was occurring daily in ED but not on the acute adult inpatient units.  

  Referrals to CMHS don t provide a clear or immediate outcome. Inpatient stakeholders 
identified that often when a referral was made, it was unclear if the consumer would be seen, 

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Review of consumer flow across the mental health stepped system of care 
 

when and how regularly even if they had asked for daily visits for a week.  I m not sure what 
actually happens with the referrals  noted one consultant psychiatrist.  

  Forensic consumers are often in acute adult mental health beds for long periods. A number 
of stakeholders noted that forensic consumers awaiting transfer to forensic beds spent 
prolonged periods of time in  locked beds  in acute mental health units. A specific issue noted 
was delays associated with court adjournments, which  often occur because of lack of cells  
or  if G4S cannot provide an escort . If the consumer s court hearing is adjourned they may 
then stay in for an additional eight week period, which was reported as the  standard next 
court date scheduled . 

Cultural issues and challenges in service settings are pervasive: 

  Learned helplessness   for example a psychiatrist talking with a nurse manager at morning 
meeting the manager reported  we have six people waiting in ED, can t do anything about 
that lets go on to something else   

  Resentment about  loosing acute mental health beds  there was debate about  whether the 
new ICC beds meant to be augmenting or replacing .  We lost 20 acute and gained 15 ICC 
beds , reported a psychiatrist.  

  There is no sense of urgency when clients wait for longer than 4hrs or 8hrs or 24 hours in ED, 
as it happens so commonly the escalation plans are no longer in effective use or working as 
intended. It was also noted in the medical record audit where consumers were delayed in ED 
the notes did not provide indication of a sense of urgency or of staff following the situation 
up; on many occasions it was repeatedly noted that the consumer was waiting for a bed. 

   Parallel processing  of mental health assessment and referral is not occurring in ED. ED 
clinicians reported they often provide services, review and assess the clients but it is not until 
the  medical clearance  that mental health clinicians then start their assessment and planning. 
This potentially prolongs the consumer s stay in ED and could often be done in  parallel  to the 
acute medical processes. In many other jurisdictions in Australia there are initiatives focussed 
on this issue with a focus on promoting the use of a  preliminary assessment  conducted by 
mental health clinicians in the emergency department environment to start the assessment 
process.  

   Medical clearance  in ED has  become the default  before transfer to an inpatient bed. This 
often creates an additional and unnecessary layer of review for the consumer, when 
historically many consumers would have been directly admitted to an acute bed with no ED 
involvement.  

  The  focus on risk  has overtaken other considerations. This can be counterproductive for 
the consumer and commonly causes delays in discharge, transfer and may actively work 
against services treating and supporting consumers in the  least restrictive environment .     

  It was reported that some staff continue to work passively with consumers with the staff  in 
the fish bowl  and  consumers out there  rather than working together and actively trying to 
engage and get consumers home. 

   We are working in silos with no one responsible or accountable across the client s journey.  
For example from ED to Inpatient there are different teams, different psychiatrists,  the same 

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Review of consumer flow across the mental health stepped system of care 
 

is true for ICC, for rehab, and for community no one can say yes this person needs to admitted 
and yes we will take this person out of the acute unit and manage them in the community . 

  There is a  disincentive to work hard to clear beds , for example one consultant reported that 
they could work all day to clear six beds on the ward but at the end of the day they may still 
not be able to clear all the consumers sitting in their ED because of other consumers both from 
out of area and in area who had been waiting longer being prioritised.  

 

 

 

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Review of consumer flow across the mental health stepped system of care 
 

3. Key findings 

To identify and synthesise the key findings of the review KPMG considered 
the weight of evidence from the stakeholder consultations, the medical 
record file audit and service data analysis before contextualising the issues 
in light of current better practice models and directions in leading 
jurisdictions.  

3.1 Leadership and direction 
  Clinical governance structures   there is a diffuse model of who makes the decision to admit 

the next consumer to an inpatient bed. If the ED is overflowing with mental health consumers 
a Clinical Director is not able to make decisions about who needs to go where or safely clearing 
room in the wards, this is delegated to other psychiatrists who have consumers on their 
individual  bed cards  and the access to the next available bed is negotiated with the bed 
managers, and often waits until the morning bed management meeting.  We have a system 
where consumers are prioritised for beds based on how long they have been in ED not on their 
clinical acuity .  We often say who is the boss?   The decision on who comes into the next 
acute bed is made by the flow co-ordinator .  Governance is an absolute mess    it s a 
struggle to know who is in charge . 

  Clinical governance leadership   no one has clear ownership and accountability for 
performance of mental health services. There is limited ownership, responsibility and 
accountability for services provided across the consumer care continuum. While there is 
ownership of issues at a local unit level this becomes ambiguous at the Mental Health Service, 
LAHN and state level. The lack of clarity about governance is a significant issue, so much so 
that a group of clinicians have had an ongoing challenge regarding the issue in the Australian 
Industrial Relations Commission  for over 18 months . 

  The timeliness of when a referral is received to acceptance is unclear? There is a passive 
system or referring and waiting with limited feedback mechanisms in place 

3.2 The model of care 
  ED has become the service entry point, creating a series of related issues  

   People go to ED because they don t know where else to go .I ve worked in the system for 
years and I don t have any better options .  

  Consumers and carers don t know how best to access services other than via ED.  There is a 
fear of how best to access services, there has been so much change in recent years it s difficult 
to know where to go, there is only one  walk in centre  which is fantastic but otherwise it s the 
Mental Health Triage line or ED. People don t want to ring the triage line because they are in 
crisis only to be told to have a warm cup of Milo.  

  There is variable consumer input into care planning although one site did demonstrate use of 
a consumer care planning form. In many cases the initial focus was on stabilising the consumer 
and diagnosis. Little discharge planning was discussed at admission and limited carer input was 
identified throughout the admission (acknowledging that in a few cases the consumer 
requested the carer not be contacted). 

 

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Review of consumer flow across the mental health stepped system of care 
 

  Centralised bed management appears to be adding time and layers to the decision making 
and not speeding up access or improving transparency of the decision making. The BAS list 
 Bed Allocation System  queuing process has taken away the ability to respond to local need 
and limited the level of local ownership. 

  Admission and access process challenges   currently apart from the one meeting at 10:30am 
for bed management there are no other regular opportunities (apart from ad hoc discussions) 
to prioritise consumers access to beds based on clinical acuity rather than simple queuing time. 

  ICC model is seen as originally designed as  too exclusive  so the consumers who came to the 
beds where  ready for rehab  and  engaged  in their own recovery, for example they need to 
be  motivated to do meal preparation and cooking for the group . Over time this criteria has 
the potential to restrict consumers who may have less motivation including those with chronic 
presentations or negative symptoms of Schizophrenia for example. Anecdotally managers of 
the ICC beds noted that many consumers had primary diagnosis of personality disorders, with 
a number having regular short admissions to an ICC bed to prevent acute crisis  our core group 
is female consumers with a Borderline Personality Disorder  noted one manager. Key 
challenges associated with this model are balancing the equity of access to the ICC beds for all 
consumer groups. The recently trialled model in the SALHN ICC of 3/15 beds designated for 
those who don t meet the  traditional criteria  known as the  blue dot people  has shown 
positive signs of broadening access to more consumers without creating an ongoing  bed block  
issue. This group of consumers receive  more targeted IBS packages, rehabilitation and 
transitional planning for community transfer . 

  Consumers eligible for the ICC beds must be referred by clinical staff and  deemed low 
risk . 

  Accommodation came up frequently as the key barrier to discharge from inpatient units, but 
there was limited evidence of active work to overcome these issues noted in the medical 
record file audit.  

  There is  a recognition that the early discharge period is an  at risk  period but there is limited 
clarity about follow up and regularity for at risk consumers who would otherwise do well in 
the community 

  Community Mental Health Services -  What has been lost is the ability to provide intense 
support for those who need acute support in the community before going back to primary 
care . For example a psychiatrist reported  I might speak with my colleague about a consumer 
who needs daily support for the next week and they agree to the referral but then come back 
and say they can t take it after talking with their resource manager . 

  Community Mental Health Services have limited interaction with the acute inpatient services, 
such a daily teleconference in the morning,  inreach is largely by request and it s often on the 
day of discharge if it occurs at all. There is opportunity for early engagement on the wards, the 
current system creates a lack of access for assertive community follow up for consumers.   

  Community Mental Health Services commonly admit consumers requiring admission 
through ED (274 consumers out of 5,272 separations or five per cent where admissions to 
inpatient units identified as  community  referral, in 2013-14) with limited other face to face 
options for people presenting in crisis, bed flow managers prioritise long stay ED consumers - 
creating a cycle of demand issues. 

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Review of consumer flow across the mental health stepped system of care 
 

3.3 Demand and supply 
   It s not about beds, people just want appropriate accommodation and care packages . 

Consistent feedback from the vast majority of stakeholders was that  we have enough beds  
but there is  no incentive to manage them more actively  

  In South Australia in 2015 the mental health acute adult bed levels are identified as 22.3 beds 
per 100,000 of population (excluding statewide beds) or 26.5 (including statewide beds) per 
100,000 of population, compared with the national average of 23.5 beds per 100,000 of 
population3.   

  Based on the last census in 2011 data provided by the AIHW compared state and territory 
adult acute mental health beds per 100,000. These data highlighted SA had a rate of 24 beds 
per 100,000 population compared to a national average of 23.9 beds per 100,0004. 

  The SA metropolitan bed stock compares to other states such as Victoria favourably for bed 
stock where the 2012-13 metropolitan acute adult bed average was 1.73 per 10,000 adult 
population or the equivalent of 17.3 beds per 100,000 adult population (excluding specialty 
beds)5. It should be noted however Victoria has a very mature community mental health 
sector, which supports this bed profile. 

  While directly comparable jurisdictions and bed averages are not available for the SA 
metropolitan adult acute mental health beds, it appears that the current level of beds for the 
population served is appropriate. 

  Geographical cover and access to ICCs is uneven. For example NALHN not having an ICC 
physically in the region makes it difficult to access and challenging for consumers to go out of 
the area to access a service. 

  The system has not responded to changes in absolute bed numbers   still working on the 
historical philosophy of  managing beds  rather than considering appropriate consumer flow. 

3.4 Service and outcome trends 
  Long stays in ED are creating other pressures and issues   for example the carer consultant 

was of the view they needed carer representatives in EDs because of the numbers of mental 
health consumers staying there for so long, but admits ideally they shouldn t be there and 
other settings would be more appropriate and ultimately more people in ED may just add to 
the overcrowding. Critically the consumers who stay longer in ED are often sedated and 
shackled and a number have  code black  incidents called because of aggression and agitation. 
This is a serious human rights issue and is not well documented or reported in ED, which has 
not been traditionally seen as part of the  mental health service stay  as highlighted in the 
medical record audit. Perhaps somewhat surprisingly there appears to be a culture of adapting 

3 Based on data provided by the SA Health, Mental Health and Substance Abuse Unit, Systems Performance, 
February 2015. Based on 2011 Census population figures. 
4 https://mhsa.aihw.gov.au/resources/facilities/beds/ accessed 3 March, 2015 
5 
http://docs.health.vic.gov.au/docs/doc/09B463676900D189CA257CB500081E5C/$FILE/API%20Summary%20201
2_13_Q4.pdf accessed 3 March 2015 
 

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Review of consumer flow across the mental health stepped system of care 
 

to the issues and accepting them with a lack of outrage amongst all groups interviewed. There 
is limited recognition of the clinical inappropriateness of disturbed consumers being kept in an 
ED because they are too disturbed to be managed in a specialist MH ward unless there is a 
high support or PICU bed available. 

  The number of direct admissions to inpatient units from ICC beds is limited data shows the 
admissions of consumers to acute beds from ICC is very limited and when it occurs it is not 
uncommon for this to be into ED first prior to acute bed admission, even when an ED stay is 
not required. This challenge reinforces the issue of  strict acceptance criteria  in the ICCs if the 
staff feel they are unable to  step consumers up  to acute beds if they become too unwell to 
be managed in ICC then they are likely to want consumers who are even lower risk of becoming 
unwell. 

  Discharge planning is not occurring on admission   the medical record audit findings 
highlighted that discharge was largely planned at the end of admission and not in advance, 
either the day before or on the day of discharge. The focus of the treatment plan was acute 
care, medication changes or stabilisation and assessment. Discharge was commonly identified 
as 2-3 weeks or unknown and then not actively monitored, creating ambiguity for staff and 
consumers about the likely length of stay in hospital. 

  Clinical decisions on the wards seem to be made on the basis of what may be best for that 
individual inpatient but with less regard for the needs of more acutely unwell consumers 
who the service also has a responsibility to. 

  Overall there is poor discharge summary distribution within 24 hours   commonly varied 
between days and months. Of the 196 medical records audited only 39 per cent had evidence 
of a discharge summary being sent within 24 hours of discharge. The exception was ICCs where 
100 per cent of discharge summaries were transmitted within 24 hours of discharge. 

 

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Review of consumer flow across the mental health stepped system of care 
 

4. Recommendations  

Based on the findings of the review, analysis of the service data trends and the 
critical issues identified the following recommendations are put forward.  

 

 

Recommendations: 

1. No additional adult acute mental health inpatient beds are required at present, SA 
benchmarks well in terms of bed capacity. 

2. Clear responsibility for consumer outcomes is required, at present there is a lack of clear 
accountability and fragmented decision making. This should involve: 

a. Accountability for outcomes being placed at the LHN level 
b. Joint Clinical and Administrative oversight of the public mental health system 
c. Clear allocation of responsibilities between the clinical and administrative lead 
d. There should be a single clinical and administrative oversight of all elements of 

public mental health within each LHN: covering Community, ICC, inpatient and ED 

3. Coupled with responsibility for outcomes, the clinical and administrative lead must also 
be given a clear allocation of resources to deliver and flexibility in the use of those 
resources: 

a. Each LHN should have a clear allocation of acute adult inpatient, ICC, and 
extended care beds and of community mental health resources. 

i. This will require some allocation of ICC beds to NALHN 
ii. This will also require an allocation of rehabilitation beds to each LHN 

b. The central Bed Allocation System which reduces the clarity of accountability for 
outcomes and can act as a disincentive to improve consumer flow should be 
removed.  

4. Revise the model of care for ICC beds. In the Longer term the model of care for ICC should 
be shifted to meet the post-acute needs of a broader cohort of consumers such that it:  

  places an emphasis on those who can be safely managed in the ICC environment 
rather than only accepting those consumers who are  low risk  

  considers implementing a range of medication management options for ICC 
consumers  

  shifts from requiring consumers to set their own goals to the shared identification 
of achievable goals for consumers who need step down from acute wards 

  allows use of the ICC stay to identify accommodation requirements 
  reflects a broader diagnostic cohort including those with more complex care 

needs. 

5. Establish a High level Statewide Mental Health Service Leadership group responsible to 
enact the following recommendations once endorsed. The representation should include 
representatives from SA Health Executive, LHN Executive and Clinical Directors, Service 
Managers and Consumer and Carer representation.  This group should support local 
clinical leadership, accountability and responsibility to markedly improve consumer flow 

 

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Review of consumer flow across the mental health stepped system of care 
 

across community, ED, inpatient areas and ICCs. This group may be an adaption of an 
existing group such as the Mental Health Portfolio Executive. 

6. Promote leadership of mental health service delivery and consumer flow by: 
a. Re-establishing a sense of urgency and accountability to ensure that no mental 

health consumer stays in ED for longer than 24 hours along with local ownership 
of consumer flow with central accountability for performance. 

b. Re-invigorating clear escalation plans to avoid consumers staying in the ED any 
longer than clinically required  within a 12-18 month period SA Health need to 
meet the Minister s targets and National Emergency Access Targets (NEAT) for 
mental health consumers presenting to ED. This will involve a whole of service 
approach to improving consumer flow matching capacity, via improved discharge 
planning and follow up, with current demand for acute beds. 

c. Increasing the linkages between the inpatient and community mental health 
teams.  This will involve a whole of service approach to improving consumer flow, 
matching capacity, via improved discharge planning and follow up, with current 
demand for acute beds. A focus should be on providing the power and confidence 
to discharge consumers and ensure safe follow up in the community, including 
potential changes in practice such as daily in reach to identify appropriate 
consumers for community follow up. 

d. Building staff competency in crisis/acute community management. Recent 
changes in CMHS have promoted a generalist approach which should not be lost 
but the ability to work with clients who are at higher levels of risk and visit 
regularly e.g. twice a day if required was reported as being lost   this is a key 
component of the  stepped model  if consumers are to avoid ED presentations. 
The ability for more services to support consumers with moderate levels of risk is 
also one that should be spread beyond the current environment where the main 
option is acute inpatient stay, support for this group of consumers via Community 
Mental Health Services and ICCs is needed. 

e. Supporting the walk in centre model, or similar  walk in assessment/intake  
community based models providing options away from ED for people with acute 
mental health needs to present for assessment. 

f. Improving the transparency of decision making and access to extended care beds 
- allowing area clinical directors to prioritise the next consumer admitted and 
discharged for their area. 

g. Promoting awareness and education to health service staff about the 
inappropriateness of keeping consumers who require a PICU bed in ED. 
Transitional arrangements such as specialling should be clear and review and 
escalation procedures available 24 hours a day seven days a week. These beds 
are a critical resource often required after hours and for short periods during an 
admission, stakeholders often reported having to  make a closed bed . Ensuring 
the maximal usage of such bed stock is critical for overall consumer flow in the SA 
Mental Health system.  

h. Refining central reporting and service indicators to enable ongoing evaluation at 
a whole of system level. (across acute, community, ED, SECU, ICC, and CRC) 
including a review of the current  dashboard indicators  and development of a set 
of key metrics for clinical director and exec monitoring including the potential 
development of targets and performance measures that are consumer rather 

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Review of consumer flow across the mental health stepped system of care 
 

than service focussed such as unplanned 28 day readmission rates for consumers 
with Community Mental Health Service follow up. 

4.1 On the horizon - What is needed longer term? 
In line with broader SA Health changes and the current  Transforming Health  directions this review 
and its recommendations provide a basis to not only modernise and align SA Mental Health 
services with better practice they also create an opportunity to build a sector that attracts the best 
clinicians and staff by promoting excellence in mental health care. Sending a clear message about 
the issues identified in the review and how seriously SA Health is now working towards resolving 
these is an important step forward for a sector that has had a number of previous reviews and 
evaluations conducted but limited broad implementation of solutions. While specific service 
elements or components have needed change in the past this review sets up the potential for 
broader reform and ownership of change across a number of key components of the mental health 
service sector.  

4.2 Future considerations 
While the current review had a relatively broad scope there are a number of mental health service 
delivery areas beyond the scope of the current review, which were identified as requiring further 
consideration. These are: 

  Population based bed modelling including the use of  muck up  for mental health services - 
The development of an activity planning approach to mental health services should be 
considered.  This should provide a clear articulation of the future demand for mental health 
services with consideration of the population growth, ageing, geographic distribution and 
service model impacts.  This will provide a clear basis for future planning of mental health 
services at a statewide and local level. Improved system understanding and planning will 
require changes to information systems to allow tracking of the consumer journey through 
various mental health services. 

  A detailed governance structure review and Local Health Network structure relating to the 
delivery of mental health services. While a formal review of the clinical governance structures 
in place for mental health services was beyond the scope of the current review a common  and 
critical issue highlighted was  who holds the risk  and confusion about  who is ultimately 
responsible . Clarity regarding accountability for service delivery is central to SA Health being 
able to discharge its responsibilities to the people of South Australia.    

  A lean/clinical redesign project to model consumer flow, decision making and key interface 
points within the mental health consumer  stepped model of care  with a particular focus on 
ED disposition. As limited linked data and whole of consumer journey data is available across 
service settings a sample of detailed consumer journey mapping or value stream mapping is 
likely to illuminate root causes of flow issues and allow for more targeted local improvements 
to be made. 

 

 

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Review of consumer flow across the mental health stepped system of care 
 

Appendix A: List of stakeholders consulted 
During the course of the review the following stakeholders were consulted using a semi structured 
interview tool: 

  Dr Peter Tyllis, the then Chief Psychiatrist 

  Rohan Dhillon, Consultant Psychiatrist QEH 

  Prashant Tibrewal, Consultant Psychiatrist QEH 

  Acting Carer Consultant 

  Acting Consumer Consultant/Senior Project Officer 

  Sue Crouch, ICC Team Manager SALHN 

  Acting ICC Team Manager CALHN 

  Dr Eli Rafalowicz, Clinical Director NALHN 

  Cornelius Takawira, Flow Coordinator/Bed Manager CALHN  

  Dr Darryl Watson, Clinical Director CALHN 

  Dr Jorg Strobel, Clinical Director CHSA MHS 

  Ruth Lange, Network Manager Rural &amp; Remote 

  Sue Tiver, Clinical Services Coordinator, Cramond Clinic 

  Dr Titus Mohan, Consultant Psychiatrist FMC 

  Dr Jim Lally, Consultant Psychiatrist 

  Dr Leslie Stephen, Consultant Psychiatrist 

  Dr Raghu Parthasarthy, Cinical Lead Psychiatrist, Western Mental Health 

  Ms Dulcey Kayes, Senior Nurse FMC 

  Dr Andrew Champion, Clinical Director, Mental Health, Outer South 

  Dr Andrew Blyth, ED Physician FMC  

  A/Prof Geoff Hughes, Director Critical Care Services, CALHN 

  Dr Megan Brooks, Consultant ED RAH 

 

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Review of consumer flow across the mental health stepped system of care 
 

Appendix B: Stakeholder consultation guide 

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Project Information 

SA Health have contracted KPMG to undertake a review of Mental Health Service consumer flows across the 
 stepped care  continuum with a particular focus on emergency department care, acute adult mental health 
inpatient beds and intermediate adult beds in metropolitan areas. 

The review will involve: 

  A high level analysis of adult mental health consumer flow data across the various components of the  stepped 
care  system. 

  Targeted consultation with key stakeholders involved in the care of mental health consumers  

  A medical record audit review of a random sample of recent inpatient consumer  episodes of care 

  An interim presentation of findings to a SA Health Steering Group  

  A final report outlining the review findings and recommendations. 
A specific focus of the review is trying to understand the current protocols and processes in place locally to 
facilitate discharge from hospital and how decisions are made to estimate discharge likelihood and overcome any 
potential barriers to community care follow up. 

Semi-structured interview tool  

A semi-structured interview tool is used to promote consistency across the  areas of enquiry  with each of the 
key stakeholder groups consulted as part of the review. 

 

Areas of enquiry 

Background  

  Can you provide a short overview of your role as it relates to the provision of service to mental health 
consumers? 

Overview 

  How would you describe the  stepped model of care  for mental health services in South Australia?  

  Is the model working as intended? Why?  
  

Health Ageing and Human Services 

Review of SA Health  Stepped Care  Model for Mental 
Health  

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System components/settings 

  Recent service trends have identified some challenges in how the  stepped care model  works in practice in 
acute metropolitan settings. Do you think there are particular services or transition points where the model is 
not working as intended? Why? 

  Are there specific challenges you are experiencing in your service relating to care for mental health 
consumers? If so what are they? 

  Has there been any attempt to implement changes or overcome these challenges locally? (if applicable) 

  What impediments or issues have you noticed over recent times that impact consumer length of stay in acute 
inpatient beds or ICC beds? 

  Are there practical steps that you think can be taken to overcome some of these issues?   

  Are there specific discharge planning challenges or issues that you commonly face? If so what are they and 
what have you found has worked well to overcome these for consumers? 

Opportunities 

  What do you think can be done to improve the acute services provided to mental health consumers in South 
Australia? 

  Are there particular process or practice changes that you think would make a difference to mental health 
consumers in acute metropolitan settings? 

  Do you have any other comments related to the review? 
 

 

 

 
 

 

 

 

 

Further information  

For more information, please contact either: 

Andrew Dempster 
KPMG Project Manager  
03 9288 6974 
adempster@kpmg.com.au  

Jenny Richter 
Deputy Chief Executive, System Performance 

Jenny.Richter@health.sa.gov.au  

 

 

 

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Review of consumer flow across the mental health stepped system of care 
 

Appendix C: Medical record audit tool 

Mental Health consumer discharge planning 
Audit Tool 

Information Sheet and Guide 
Purpose - SA Health have contracted KPMG to undertake a review of Mental Health Service consumer flows across the  stepped care  continuum with a 
particular focus on emergency department care, acute adult mental health inpatient beds and intermediate adult beds in metropolitan areas. The purpose 
of the medical record review is to undertake a semi-structured review of the key clinical decision making processes evident in the medical record as they 
relate to planning the consumers care with a particular focus on discharge or transfer processes. Reviewers should seek to extract key flags and processes 
in the medical record which highlight: 

  The identification of barriers to discharge/transfer (this may involve secondary review, referral delays, or specific consumer circumstances for example 
homelessness highlighting the need for accommodation support; amongst other things) 

  The focus of treatment decisions and whether consumer care planning consistently addresses the  next step  of the journey such as transfer or 
discharge 

  Evidence of clinical review, assessment and planning activities and the impact on discharge/transfer and consumer length of stay in emergency 
department and inpatient settings 

Audit Tool Guide:  

The medical record audit tool is to be completed for each individual consumer. All fields are to be assessed and completed even if some fields require a 
N/A rating. For the purposes of the medical record audit review the assessment should only be made based on information relating to the most recent 
 episode of care  for the consumer which may include one or more of the in scope components of the review, specifically ED, acute inpatient mental health 
bed or Integrated Community Care bed. While the episode of care may also include settings outside those specifically mentioned they are outside the scope 
of the current review and should be noted as a discharge or transfer destination for reference only.  

Related clinical and mental health standards/guidelines:  

Some of the relevant guidelines and standards considered in developing and refining the current audit tool have included: 

40 
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Review of consumer flow across the mental health stepped system of care 
 

  The Australian National Mental Health Standards6 should be considered, particularly relevant are the following sections: 

  Section 1.18 - Implementing processes to enable partnership with patients in decisions about their care, including informed consent to treatment. 

  Section 10.4.4 - The MHS actively plans as early as possible in the course of psychiatric inpatient admission, for the discharge of the consumer 
from inpatient care. 

  Section 10.5.9 - The MHS ensures that there is continuity of care or appropriate referral and transfer between inpatient, outpatient, day patient, 
community settings and other health /support services. 

  Section 10.5.16 - The MHS endeavours to provide access to a range of accommodation and support options that meet the needs of the consumer 
and gives the consumer the opportunity to choose between these options. 

  Section 10.6.3 - The MHS has a process to commence development of an exit plan at the time the consumer enters the service. 

  Section 10.6.4 - The consumer and their carer(s) and other service providers are involved in developing the exit plan. Copies of the exit plan are 
made available to the consumer and with the consumers  informed consent, their carer(s). 

  Recognising and Responding to Deterioration in Mental State: A Scoping Review, Australian Commission on Safety and Quality in Health Care7. 

  NICE guideline: Transition between inpatient mental health settings and community or care home settings - draft scope for consultation (30 
September   28 October 2014)8 

  A positive outlook: a good practice toolkit to improve discharge from inpatient mental health care, National Institute for Mental Health in England, 
20079 

  ACHS Standard 1.1, Criterion 1.1.1 Assessment ensures current and ongoing needs of the consumer/patient are identified 

6 National standards for mental health services, 2010 
http://www.health.gov.au/internet/main/publishing.nsf/Content/CFA833CB8C1AA178CA257BF0001E7520/$File/servst10v2.pdf accessed December 2014. 
7 Recognising and Responding to Deterioration in Mental State: A Scoping Review, July 11 2014 http://www.safetyandquality.gov.au/publications/recognising-and-responding-to-
deterioration-in-mental-state-a-scoping-review/ accessed December 2014. 
8 NICE guideline: Transition between inpatient mental health settings and community or care home settings - draft scope for consultation (30 September   28 October 2014) 
http://www.nice.org.uk/guidance/gid-scwave0711/resources/transition-between-inpatient-mental-health-settings-and-community-and-care-home-settings-draft-scope-2 accessed 
December 2014 
9 http://www.scie-socialcareonline.org.uk/a-positive-outlook-a-good-practice-toolkit-to-improve-discharge-from-inpatient-mental-health-care/r/a11G00000017qkBIAQ accessed 
December 2014 

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Review of consumer flow across the mental health stepped system of care 
 

  ACSQHC Clinical Handover National Standards 610 

10 ACSQHC Clinical Handover National Standards 6 http://www.safetyandquality.gov.au/wp-content/uploads/2012/10/Standard6_Oct_2012_WEB.pdf accessed December 2014 
42 

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Cooperative ("KPMG International"). 
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Review of consumer flow across the mental health stepped system of care 
 

Mental Health consumer discharge planning 
Audit Tool 

 

Audit: Encounter Record ___ of ___ Facility:  

Consumer/ Unit Medical Record 
Number: 

Time/Date of 
presentation (ED)   if 
applicable: 

Time/Date of 
Admission: 

Time/Date of transfer (if 
applicable): 

Time/Date of Discharge: 

 ____/____/20___ ____/____/20___ ____/____/20___ ____/____/20___ 

Involuntary status Involuntary for all or part of this episode Y / N 

New consumer to facility or 
previous presentation/admission 
to facility 

New consumer to the service Y / N 

Length of Stay: (in days) Reviewer: Location of review:  

 

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Review of consumer flow across the mental health stepped system of care 
 

PART A: Emergency Department stay (if applicable) 

Information  

 

Documented in Medical Record Evidence / Example Comment  

1 Evidence of 
assessment of 
consumer for 
mental illness 

Yes No Partial N/A Such as through use of a structured mental health triage tool  

2 Evidence of a 
diagnosis of 
mental illness 

Yes No Partial N/A   

3 Evidence of 
referral to mental 
health 
team/service/unit 

Yes No Partial N/A 
Evidence of discussion with 

psychiatrist, mental health clinician or 
liaison 

 

4 Evidence of senior 
medical officer 
input/review 

Yes No Partial N/A  
 

5 Use of mental 
health risk 
assessment tools 

Yes No Partial N/A  
 

6 Discharge or 
transfer planning 
to mental health 
unit/bed 

Yes No Partial N/A  

 

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Review of consumer flow across the mental health stepped system of care 
 

Information  

 

Documented in Medical Record Evidence / Example Comment  

7 Discharge/transfer 
delays noted  Yes No Partial 

 
 N/A 

This includes notes of consultation with 
the patient flow/bed manager in 

relation to available beds 

 

 

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Review of consumer flow across the mental health stepped system of care 
 

PART B: Admission to Acute inpatient bed or Integrated Care Centre bed 

Information  

 

Documented in Medical Record Evidence / Example Comment  

8 Admitted from 
source  Yes No Partial N/A 

Identify location/service setting the 
consumer was admitted from  

9 Evidence of 
discharge planning 
during initial 
consumer 
assessment 

Yes No Partial N/A   

10 Involuntary status 
of the consumer 
for all or part of the 
admission 

Yes No Partial N/A Is a treatment order in place for all or part of the admission?  

11 Evidence of 
change of 
consumer status 
during admission 
from voluntary to 
involuntary 

Yes No Partial N/A (include timing of such event post admission if applicable)  

12 Evidence of a 
treatment plan at 
the time of 
admission 

Yes No Partial N/A   

13 Evidence of 
implementation of 
the treatment plan 

Yes No Partial N/A   

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Review of consumer flow across the mental health stepped system of care 
 

Information  

 

Documented in Medical Record Evidence / Example Comment  

14 Evidence of 
consumer 
involvement in 
care planning 

Yes No Partial N/A   

15 Evidence of carer 
involvement in 
care planning 

Yes No Partial N/A   

16 Identification of 
potential barriers 
to 
discharge/transfer 
noted in medical 
record 

Yes No Partial N/A   

17 Evidence of 
progress towards 
discharge and 
overcoming any 
barriers (if 
applicable) 

Yes No Partial N/A  

 

18 Evidence of 
Community Mental 
Health Service 
inreach pre-
discharge 

Yes No Partial N/A  

 

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Review of consumer flow across the mental health stepped system of care 
 

Information  

 

Documented in Medical Record Evidence / Example Comment  

19 Evidence of 
communication 
with relevant 
community 
stakeholders 

Yes No Partial N/A e.g. GP 

 

20 Evidence of 
regular formal 
consumer review 

Yes No Partial N/A  
 

21 Evidence of 
consultant 
psychiatrist review 

Yes No Partial N/A  
 

22 Evidence of actual 
delay to discharge/ 
transfer 

Yes No Partial N/A 
If applicable include delay reasons e.g. 

waiting for review, medication/script, 
transport etc  

 

23 Discharge/ 
transfer 
destination 

Yes No Partial N/A  
 

24 Evidence of 
discharge 
summary 
transmission 
within 24 hours of 
discharge 

Yes No Partial N/A  

 

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Review of consumer flow across the mental health stepped system of care 
 

Information  

 

Documented in Medical Record Evidence / Example Comment  

25 Evidence of 
communication of 
the discharge plan 
with the consumer 

Yes No Partial N/A  

 

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Review of consumer flow across the mental health stepped system of care 
 

PART C: Admission to Acute inpatient bed or Integrated Care Centre bed (Only if a second facility was included in the last episode of care) 

Information  

 

Documented in Medical Record Evidence / Example Comment  

26 Admitted from 
source  Yes No Partial N/A 

Identify location/service setting the 
consumer was admitted from  

27 Evidence of 
discharge planning 
during initial 
consumer 
assessment 

Yes No Partial N/A   

28 Involuntary status 
of the consumer 
for all or part of the 
admission 

Yes No Partial N/A Is a treatment order in place for all or part of the admission?  

29 Evidence of 
change of 
consumer status 
during admission 
from voluntary to 
involuntary 

Yes No Partial N/A (include timing of such event post admission if applicable)  

30 Evidence of a 
treatment plan at 
the time of 
admission 

Yes No Partial N/A   

31 Evidence of 
implementation of 
the treatment plan 

Yes No Partial N/A   

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Review of consumer flow across the mental health stepped system of care 
 

Information  

 

Documented in Medical Record Evidence / Example Comment  

32 Evidence of 
consumer 
involvement in 
care planning 

Yes No Partial N/A   

33 Evidence of carer 
involvement in 
care planning 

Yes No Partial N/A   

34 Identification of 
potential barriers 
to 
discharge/transfer 
noted in medical 
record 

Yes No Partial N/A   

35 Evidence of 
progress towards 
discharge and 
overcoming any 
barriers (if 
applicable) 

Yes No Partial N/A  

 

36 Evidence of 
Community Mental 
Health Service 
inreach pre-
discharge 

Yes No Partial N/A  

 

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Review of consumer flow across the mental health stepped system of care 
 

Information  

 

Documented in Medical Record Evidence / Example Comment  

37 Evidence of 
communication 
with relevant 
community 
stakeholders 

Yes No Partial N/A e.g. GP 

 

38 Evidence of 
regular formal 
consumer review 

Yes No Partial N/A  
 

39 Evidence of 
consultant 
psychiatrist review 

Yes No Partial N/A  
 

40 Evidence of actual 
delay to discharge/ 
transfer 

Yes No Partial N/A 
If applicable include delay reasons e.g. 

waiting for review, medication/script, 
transport etc  

 

41 Discharge/ 
transfer 
destination 

Yes No Partial N/A  
 

42 Evidence of 
discharge 
summary 
transmission 
within 24 hours of 
discharge 

Yes No Partial N/A  

 

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Review of consumer flow across the mental health stepped system of care 
 

Information  

 

Documented in Medical Record Evidence / Example Comment  

43 Evidence of 
communication of 
the discharge plan 
with the consumer 

Yes No Partial N/A  

 

 

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Appendix D. Average length of stay by ward code 2011-12 to 2014-15 
The following table provides a breakdown of average length of stay trends for acute adult mental health inpatient bed admissions between the years 2011-12 
and 2014-15 (year to date, based on the first four full months of data in this period). KPMG have not been provided the descriptors for each ward code and as 
such are not able to provide a greater level of detail. The trend in ALOS by ward code should be interpreted in conjunction with the following notes regarding 
the data analysed.  

 

Data notes for inpatient wards: 

  Data for metro hospitals only 

  Data includes sameday activity, which may include ECT admissions in some wards. 

  2011/12 and 2012/13 data based on a patient s ward on Discharge being an approved mental health ward 

  2013/14 and 2014/15 data based on a patient being in an approved mental health ward at any time during their stay 

  Data based on General/Adult wards only (i.e. excludes Child, Older Persons, and Forensic wards) 

  Data for patients aged outside of the 16-65 criteria may be included provided they were in a General/Adult ward 

  Data for patients aged &lt;16 has been excluded if their approved mental health ward was Helen Mayo House (as per standard reporting practices)  

Table 12 Average length of stay by ward code 2011-12 to 2014-15 

Hospital and Ward on discharge 2011/12 ALOS in days 

 

2012/13 ALOS in days 2013/14 ALOS in days 2014/15 ALOS in days 

FMC-4D .  .  .  28 

FMC-4GP 18.8 19.5 16.8 15.9 

FMC-5A .  .  10 .  

FMC-5F .  .  40 .  

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Hospital and Ward on discharge 2011/12 ALOS in days 

 

2012/13 ALOS in days 2013/14 ALOS in days 2014/15 ALOS in days 

FMC-5H 17.2 22.1 21.8 19.8 

FMC-5J 12.4 9.6 11.6 17.3 

FMC-5K 17.6 18.3 23 22.8 

FMC-6C .  .  21 .  

FMC-AMU .  .  2 .  

FMC-FMC .  .  1 .  

FMC-MHHH 29.2 .  .  .  

FMC-OPR .  .  1 .  

FMC-PAED .  .  23 8.5 

FMC-TL .  .  15 26 

Glenside-BC 356.3 329.6 .  .  

Glenside-BN 11.3 12 11.7 .  

Glenside-CH 18.8 16.8 17.2 .  

Glenside-EA .  .  19.3 15.1 

Glenside-ET 1 1 1 1 

Glenside-EU 23.6 23.2 23.3 .  

Glenside-KL 365.5 480.1 .  .  

Glenside-PI .  .  10.7 14.5 

Glenside-R1 1544.9 .  .  .  

55 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 

The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 
Cooperative ("KPMG International"). 

Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

Hospital and Ward on discharge 2011/12 ALOS in days 

 

2012/13 ALOS in days 2013/14 ALOS in days 2014/15 ALOS in days 

Glenside-R2 1369.8 803.8 .  .  

Glenside-RC .  .  301 .  

Glenside-RO .  109.5 209.4 .  

Glenside-RR .  .  21.8 28.7 

Glenside-VC 2383.3 1472.5 .  .  

LMH-1E .  .  37 .  

LMH-1G 15 13.9 16 18.8 

LMH-1GSEC 13.4 12.7 13.1 9.2 

LMH-2C .  .  41 .  

LMH-2E .  .  11 .  

LMH-2F .  .  1 .  

LMH-2FX .  .  42 .  

LMH-CSU .  .  .  28 

LMH-ICU .  .  14.5 .  

LMH-MHOME 20.7 25.5 .  .  

LMH-WH .  .  49 .  

Modbury-23H .  .  5 .  

Modbury-E2 .  .  .  16 

Modbury-E2O .  .  4 .  

56 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 

The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 
Cooperative ("KPMG International"). 

Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

Hospital and Ward on discharge 2011/12 ALOS in days 

 

2012/13 ALOS in days 2013/14 ALOS in days 2014/15 ALOS in days 

Modbury-HCU .  .  12 .  

Modbury-WH 11.7 14 15.9 16.7 

Noarlunga-A 16.2 15.8 24.2 .  

Noarlunga-AHH 13 12.5 19.8 .  

Noarlunga-AICU 9.9 14.1 6 .  

Noarlunga-EDM .  .  16 .  

Noarlunga-MHDU .  .  20.1 10.9 

Noarlunga-MHITH .  .  13.6 18.3 

Noarlunga-MOR .  .  17.7 20.9 

Noarlunga-WHIT .  .  .  13 

RAH-A5 .  .  .  8 

RAH-C3 17.4 14.9 16.8 16.2 

RAH-EECU .  .  1 .  

RAH-GREC .  .  1 .  

RAH-HXHP 31.6 .  .  .  

RAH-N2DC .  .  18.5 .  

RAH-P3MH .  .  1.9 2.6 

RAH-P4IC .  .  7.5 5 

RAH-PECU 1.2 1.4 1.5 1.8 

57 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 

The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 
Cooperative ("KPMG International"). 

Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

Hospital and Ward on discharge 2011/12 ALOS in days 

 

2012/13 ALOS in days 2013/14 ALOS in days 2014/15 ALOS in days 

RAH-Q6 .  .  1 .  

RAH-Q8 .  .  12 .  

RAH-R7 .  .  8 .  

RAH-R8 .  .  121 8 

RAH-S2 .  .  7 .  

RAH-S7 .  .  16 .  

RAH-T3 .  .  2 .  

RGH-1 .  .  37 .  

RGH-17 18.3 17.8 17.2 .  

RGH-2 .  .  10 .  

RGH-IC .  .  29 .  

RGH-W17 .  .  17.9 18.3 

RGH-W2 .  .  .  2 

TQEH-CRAM 12.8 11.1 11 12.5 

TQEH-EMERG .  .  2.6 3.8 

TQEH-HAHM 13.5 16.5 .  .  

TQEH-ITU .  .  .  2 

TQEH-PICU .  .  29.2 18.7 

TQEH-S1 .  .  11 .  

58 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 

The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 
Cooperative ("KPMG International"). 

Liability limited by a scheme approved under Professional Standards Legislation. 

 



Review of consumer flow across the mental health stepped system of care 
 

Hospital and Ward on discharge 2011/12 ALOS in days 

 

2012/13 ALOS in days 2013/14 ALOS in days 2014/15 ALOS in days 

TQEH-S2 .  .  7 .  

WCH-FamilyServices-HMH 16.6 18.4 20.3 22 

WCH-HMH 1 5 .  .  

Source: Mental Health and Substance Abuse Unit, System Performance SA Health, February 2015 
 

 

59 
   2015 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 

The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International 
Cooperative ("KPMG International"). 

Liability limited by a scheme approved under Professional Standards Legislation. 

 


	Disclaimer
	Table of contents
	Glossary
	Executive Summary
	The review
	Approach
	Findings
	Recommendations

	1. Context and background
	1.1 Context and reason for the review
	1.2 Scope and limitations
	1.3 Approach for the review
	1.3.1 Medical record file audit
	1.3.2 Service data analysis
	1.3.3 Stakeholder consultation


	2. The review
	2.1 Service trends/linked data analysis
	2.1.1 System level consumer flow
	2.1.2 Emergency Department presentations

	By financial year
	By financial year and hospital
	By financial year and diagnosis description
	By financial year and hour of presentation
	By financial year and arrival mode
	By financial year and departure status (i.e. Episode complete-Home, Admission to ward, Admission within ED)
	By financial year and time in ED
	2.1.3 Adult acute inpatient admissions
	2.1.4 ICC admissions
	2.1.5 Community Mental Health contacts

	2.2 Medical record audit findings
	2.2.1 Overall file review findings
	2.2.2 Emergency Department   file review findings
	2.2.3 Admission to Acute Inpatient/ICC Bed   file review findings

	2.3 Stakeholder feedback

	3. Key findings
	3.1 Leadership and direction
	3.2 The model of care
	3.3 Demand and supply
	3.4 Service and outcome trends

	4. Recommendations
	Recommendations:
	4.1 On the horizon - What is needed longer term?
	4.2 Future considerations

	Review of SA Health  Stepped Care  Model for Mental Health
	Mental Health consumer discharge planning
	Audit Tool
	Information Sheet and Guide
	Related clinical and mental health standards/guidelines:
	Mental Health consumer discharge planning
	Audit Tool

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