Mental Health Nurse Incentive Program Guidelines
July 2016
Introduction
The Mental Health Nurse Incentive Program (MHNIP) funds Providers including; community
based general practices, private psychiatric practices and other appropriate health services,
so they can engage Mental Health Nurses to help provide coordinated clinical care for
people with severe mental illness.
Mental Health Nurses must work with Psychiatrists and General Practitioners (GPs) to
provide services like monitoring a patient’s mental state, managing their medication and
improving links to other health professionals and clinical services.
These services can be provided in a range of settings, like clinics or patients’ homes, and
must be provided at no cost to the patient.
Support provided under the MHNIP targets patients with severe mental illness with complex
needs. A patient should exit the MHNIP when he or she does not require the level of
support as outlined in this document.
These guidelines provide information to Providers about delivering MHNIP services.
Transition arrangements from 1 July 2016 – 30 June 2017
On 26 November 2015 the Australian Government announced its response to the National
Mental Health Commission’s review of Mental Health Programmes and Services. The
reforms outlined in the response will transform Commonwealth mental health funding and
program delivery over the next three years to achieve a more efficient, integrated and
sustainable mental health system and to improve mental health services for Australians.
From 1 July 2016 the Central and Eastern Sydney PHN (CESPHN) will be responsible for
planning and integrating services at the regional level and better targeting services to meet
individual and local need. The role of the Mental Health Nurse in the new primary mental
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health care model will continue to focus on providing and coordinating clinical care for
people with severe mental illness, in collaboration with GPs and Psychiatrists.
For 2016-17, MHNIP funding is part of CESPHN’s primary health flexible funding pool. During
2016-2017 CESPHN is required to quarantine funds to commission mental health nursing
services from the current network of MHNIP Providers. The emphasis will be on ensuring
service continuity to existing/continuing patients, and bedding down the role of Mental
Health Nurses within a team based approach to provide clinical care to people with severe
and complex mental illness.
Continuation of the funding will enable Mental Health Nurses to continue to provide
coordinated clinical care for people with severe and complex mental illness to keep them
well in the community and reduce avoidable hospitalisations.
From 2017-18, Mental Health Nurse funding will no longer be quarantined and will fully
transition to the PHN flexible funding pool, to be allocated according to regional needs.
2016-17 service levels
The annual service levels that Providers are eligible for in 2016-17 are based on the
projected number of sessions conducted in 2015-16. To help Providers maintain their
service levels, CESPHN will monitor service levels and provide a quarterly update. This is to
make sure that allocated service levels are not exceeded by 30 June 2017. Any claims
submitted for services provided in 2016-17 in excess of an organisation’s 2015-16 session
allocation will not be paid.
Inactive Providers
During 2016-17, if a Provider does not submit any claims for the previous quarter, they will
be asked to confirm that they are still providing services and/or want to remain in the
MHNIP. If they no longer want to provide services under the MHNIP, or do not respond
within the required timeframe, CESPHN will remove them from the MHNIP and funding will
be reallocated.
Patient entrance criteria
GPs and Psychiatrists will determine which patients are eligible for services under the
MHNIP. To be eligible, all of the following criteria must be met:

The patient has been diagnosed with a mental illness according to the criteria defined in
the:
o World Health Organisation Diagnostic and Management Guidelines for
Mental Health Disorders in Primary Care: ICD 10 Chapter V Primary Care
Version, or
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o
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the Diagnostic and Statistical Manual of Mental Health Disorders - Fifth
Edition (DSM-5)
The patient’s mental illness is significantly impacting their social, personal and work life
The patient has been to hospital at least once for treatment of their mental illness, or
they are at risk of needing hospitalisation in the future if appropriate treatment and
care is not provided
The patient is expected to need ongoing treatment and management of their mental
illness over the next 2 years
The GP or Psychiatrist, engaged to treat the patient by the organisation participating in
the MHNIP, will be the main person responsible for the patient’s clinical mental health
care
The patient has given permission to receive treatment from a Mental Health Nurse
The patient is not currently on a Community Treatment Order (CTO)
The Mental Health Nurse is required to complete a patient information form on receipt of
referral for new patient into the MHNIP and send to CESPHN as outlined in Schedule 2 of
the Service Agreement.
Patient exit criteria
A patient is no longer eligible for services under the MHNIP when:

Their mental illness no longer causes significant disablement to their social, personal
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and occupational functioning
They no longer need the clinical services of a Mental Health Nurse, or
The GP or Psychiatrist, engaged to treat the patient in the MHNIP, is no longer the main
person responsible for the patient’s clinical mental health care
The patient’s mental health deteriorates and they need referral to a specialist
community or inpatient mental health service
The Mental Health Nurse is required to record when a patient has exited the program in the
Collaborative Care Management Solution (CCMS), as outlined in Schedule 2 of the Service
Agreement.
2016-17 Providers within the CESPHN region
Eligible Providers include:
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Registered GPs
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Psychiatrists
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Local Health Districts
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Aboriginal and Torres Strait Islander Primary Health Services
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Other appropriate health services
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Formal protocols for managing patients
Providers must have a formal protocol in place for managing a patient’s mental health care
under this measure.
Where Providers have patient shared care mental health treatment plans in place, the
organisation must:
 Be the primary care giver
 Observe formal protocols described within the mental health patient's shared care
mental health treatment plan in order to be eligible for payments under the MHNIP
GP Mental Health Treatment Plan
Together with the Mental Health Nurse, a GP Mental Health Treatment Plan must be
developed by GPs or an equivalent plan must be developed by Psychiatrists. These plans
must include specific reference to the roles and responsibilities of both the nurse and the
treating GP.
Treatment must be provided according to the plan and the relevant clinical guidelines for
the treatment of that mental illness. A GP or Psychiatrist must review the plan together with
the Mental Health Nurse as per the Medicare guidelines. The review should include, where
appropriate, input from a clinical psychologist, registered psychologist or other allied health
professional.
Medicare guidelines include that a formal review should occur four weeks to six months
after the completion of a GP Mental Health Treatment Plan. If a further review is required,
this can occur three months after the first review.
The steps in preparing a GP Mental Health Treatment Plan are the same as those defined in
Item 2700, 2701, 2715 and 2717 of the Medicare Benefits Schedule (MBS) for GP Mental
Health Treatment items and as outlined in Explanatory Notes A.46 of the Medicare Benefits
Schedule.
Examples of clinical practice guidelines can be found at the Royal Australian and New
Zealand College of Psychiatrists website.
Health of the Nation Outcomes Scale (HoNOS)
Mental Health Nurses must use the Health of the Nation Outcomes Scale (HoNOS) for each
patient as they enter the MHNIP. They must then measure changes to a patient’s symptoms
and functioning using these tools every 90 days, and when the patient exits the MHNIP.
These measures include the child and adolescent, adult, and older person tools.
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The Provider must ensure Mental Health Nurses engaged for the MHNIP have successfully
completed training in undertaking HoNOS assessments.
The Mental Health Nurse is required to record the HoNOS assessments scores in CCMS, as
outlined in Schedule 2 of the Service Agreement.
Eligibility requirements for Mental Health Nurses
The Provider must engage the services of a Registered Nurse under the Nurses and Midwives
Board NSW holding a current annual license certificate in accordance with the Nurses and
Midwives Board NSW (NMB).
The nurse must also be currently registered as a health practitioner with the Australian
Health Practitioner Regulation Agency (AHPRA).
The nurse must be vaccinated against dTpa, Hepatitis B, MMR, Varicella and Tuberculosis or
have commenced a course of vaccination;
The nurse must also provide proof of having a current:
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National Police check
NSW Working with Children Check
100 point identification verification check
Professional qualifications and registrations
Indemnity insurance
Functions of the Mental Health Nurse
Mental Health Nurses engaged under the MHNIP will work closely with Psychiatrists or GPs
to provide coordinated clinical care and treatment for people with severe mental illness
with complex needs.
Mental Health Nurses are to perform their role within the scope of practice for a Mental
Health Nurse founded on the RN Standards for Practice (NMBA) and the National Decision
Making Framework.
Guidance on the specific mental health nursing capabilities should be based on both the
ACMHN Standards of Practice for Mental Health Nurses 2010 and the Department of
Health’s National practice standards for including skills in the mental health workforce 2013.
Mental Health Nurse functions will include, but are not limited to, providing clinical nursing
services for patients with severe and complex mental illness including:
 Psycho-education
 Referral and service coordination
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Team care activities (e.g., joint sessions, case conferencing, clinical review, medication
review)
Care planning (e.g., Mental Health Treatment Plan development or review)
Supporting family members, or carers
Medication management (e.g., administration, managing compliance)
Referral to other services and referral coordination/follow up
Advocacy
Focussed psychological interventions (e.g., CBT, ACT, brief solution focussed therapy)
Managing co-morbidities (e.g., chronic disease, or substance misuse)
Risk management (e.g., crisis support, suicide prevention, triaging to emergency
services).
These services may be delivered face to face or via the telephone, depending on need.
The ultimate aim is clinical care and coordination to effectively support the patient’s
symptoms and avoid unnecessary hospitalisation.
Mental Health Nurse caseloads for 2016-17 in the CESPHN region
The Provider can engage Mental Health Nurses from between 3 and 35 hours per week, per
nurse. The Provider can engage more than one Mental Health Nurse.
As a guide, a Provider engaging the services of a full-time Mental Health Nurse should have
a current minimum case load of 20 individual patients with a severe mental illness per week,
averaged over 3 months.
When taking into account patient turnover, the expected annual caseload managed by a
full-time Mental Health Nurse is 35 patients with a severe mental illness, most of whom will
require ongoing care over the course of the year.
It is expected that a full-time Mental Health Nurse engaged for 35 hours per week would
provide an average 25 hours of clinical contact time per week, with the balance of time
spent in related tasks. Related tasks include interagency liaison, case planning and
coordination, clinical briefings to relevant GPs or Psychiatrists and travel. Any administrative
requirements related to the Provider should not be included in this time.
Under the MHNIP, the typical caseload of a full-time Mental Health Nurse will comprise of
patients with different levels of care requirements that fall broadly into three groups:
Low care - patients in this group include individuals with severe mental illness whose clinical
symptoms are well controlled but who would be at risk of relapse without ongoing clinical
supervision.
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Medium care - patients in this group will have active symptoms which can only be well
controlled with regular clinical contact (e.g. fortnightly) and need close monitoring to
prevent deterioration.
High care - patients will have persistent or fluctuating clinical symptoms, despite active
treatment. They are at risk of hospitalisation or being lost to care if not actively managed.
Patients in this group, on average, require frequent clinical contact.
Requirements for eligible Providers
To be eligible for the MHNIP, Providers must be able to verify the following when requested:

Appropriate insurance coverage, including:
Worker’s compensation in accordance with relevant state or territory legislation
o
Public liability insurance of $20 million or more. Insurance level may vary for sole
traders
o
Professional indemnity insurance of $20 million or more for clinical and non-clinical
work. Insurance level may vary for sole traders
o
Vicarious liability cover of $1 million or more, where the Mental Health Nurse is
engaged by the organisation and is carrying out medical procedures or providing
medical advice
Where the Mental Health Nurse is not engaged by the eligible organisation, the same
o
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minimum levels of insurance coverage must be maintained, although some or all of the
policies may be maintained by the Mental Health Nurse
Ongoing maintenance of the required insurance coverage
Adherence to relevant professional standards, and to the National Practice Standards
for the Mental Health Workforce 2013
The presence and use of patient reminder and recall systems
The appropriate qualifications and experience of Mental Health Nurses engaged (see
Eligibility requirements for Mental Health Nurses above)
The consistency of terms and conditions for the engagement of Mental Health Nurses
with relevant New South Wales legislation
The maintenance of minimum levels of contact with patients with a severe and complex
mental illness that meet their individual clinical requirements, this may include
telephone contact
The presence of formal protocols for managing a patient’s mental health care under the
MHNIP, including:
o
A GP Mental Health Treatment Plan for GPs or equivalent plan for Psychiatrists,
developed in collaboration with the Mental Health Nurse (these plans must include
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o
o
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specific reference to the roles and responsibilities of both the nurse and the
treating medical professional). This should be reviewed according to the MBS
A Mental Health Nurse assessment of eligible patients at entry, every 90 days and
when a patient exits the MHNIP using the HoNOS assessment tool, including the
child and adolescent, adult, and older person tools
The appropriate training of Mental Health Nurses engaged in using HoNOS
The availability of dedicated working spaces within the clinic or as appropriate for
engaged Mental Health Nurses during working hours
The availability of clinical care oversight, including regular reviews of care provided by
Mental Health Nurses
The presence of support systems for Mental Health Nurses, such as access to training
and peer mentoring opportunities
The maintenance of records relating to Mental Health Nurse engagement
The maintenance of case records by engaged Mental Health Nurses that record
activities undertaken. Important: these activities must be consistent with the role
described under Functions of the Mental Health Nurse
The services provided by Mental Health Nurses will be at no cost to the patient
Agreement to provide CESPHN with reporting data as detailed in Reporting below
Monitoring
If requested, the Provider must provide evidence of the requirements listed above to
CESPHN in the case of an audit to ensure compliance.
A requirement under our Clinical Governance Framework is that the CESPHN will undertake
random sample clinical audits annually. As a contracted Provider you will need to participate
in a self-audit assessment.
Reporting
CESPHN is required by the Department of Health to contribute data quarterly to the
National Minimum Data Set (MDS). The Provider is responsible for ensuring relevant
information and Service data is uploaded within the required timeframes and in the format
required as per Schedule 2 in the Service Agreement.
To ensure this:


The Mental Health Nurse is required to email or fax a patient information form to
CESPHN on receipt of referral for new patient into the MHNIP
The Mental Health Nurse is required to enter every Service with a patient into CCMS
within 5 working days. Services can be recorded in durations of 30 minute; one hour;
one hour 30 minutes; 2 hours, 2 hour 30 minutes and 3 hours, depending on the time
spent delivering services to, or for, an individual patient
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
Records the HoNOS assessment outcomes in the CCMS:
o
o
o
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Upon the initial appointment with the patient
Every 90 days after this
Upon discharge from the program
In addition to entering data into CCMS on services provided to patients, the Mental
Health Nurse is required to keep a separate diary of these services for auditing
purposes.
Payments to eligible Providers
Claim payment
From 1 July 2016 the following timeframes and arrangements apply:
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For the purpose of payment, a session is 3.5 hours and must include services to, or for
at least two patients
All claims will be paid at the rate of $240 per session. This amount is intended to be
cover the salary and on-costs for engaging a Mental Health Nurse/s, including leave and
other entitlements
The Provider must issue a typed invoice to CESPHN via email [email protected] for
the services provided in the previous month by the 10th of the following month.
Invoices will be paid only when all MDS data requirements have been completed via
CCMS
Payment for sessions claimed will be made 30 working days after the receipt of a
correctly rendered tax invoice
Contact details
From 1 July 2016, all enquiries for the MHNIP are to be directed to CESPHN by email at:
[email protected] or by telephone on (02) 9330 9999
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Attachment 1
CENTRAL AND EASTERN SYDNEY PHN
Mental Health Nurse Incentive Program (MHNIP)
Patient Information Form
This form is to be completed by the Mental Health Nurse (MHN) and forwarded to
Central and Eastern Sydney PHN upon receipt of referral for each new patient.
Completed forms are to be faxed to (02) 9330 9988 or e-mailed to
[email protected]
MENTAL HEALTH NURSE INFORMATION
Mental Health Nurse Providing Service
REFERRER INFORMATION
Referrer Name
Referral Date
Referrer
Profession
Provider
Number
Practice
Postcode
Practice Name
Business
Phone
E-mail
PATIENT INFORMATION
First Name
Last Name
Date of Birth
Gender
Residential Postcode
Country of Birth
☐Yes
☐No
☐
Unknown
Does the Patient Identify as Torres Strait
☐Yes
☐No
☐
Islander
Unknown
Main Language
Other Language
Spoken
Spoken
☐Very well
☐Well
☐ Not well
☐ Not at all
☐
Proficiency in English
Unknown
☐ Employed
☐ Not Employed
☐ Student
☐
Labour Force Status
Unknown
Does the Patient Identify as Aboriginal
☐ I confirm that:

The patient has given permission to receive treatment from the Mental Health Nurse,

The patient agrees to their clinical and non-clinical information being provided to CESPHN for administration
and project evaluation purposes.
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Attachment 2
CENTRAL AND EASTERN SYDNEY PHN
Mental Health Nurse Incentive Program (MHNIP)
Assessment Form
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
Central and Eastern Sydney PHN, under contract to the Department of Health (DoH), is obliged to report on the
outcome of its commissioned activities via a Minimum Data Set (MDS) on a quarterly basis.
To facilitate this CESPHN uses a web-based program ‘Collaborative Care Management Solution’ (CCMS).
This form may be used as a temporary means of recording MDS, it replicates the ‘’Assessment’’ forms available
in CCMS.
Mental Health Nurses are required to enter every session with a patient into CCMS within 5 working days.
Name of Mental Health Nurse Providing Service
Patient CCMS ID
Date of Service
Duration of Service
☐30mins
☐1hr
Service Modality
☐Face-to-Face
Service Venue
☐Practice
☐ 1hr 30mins
☐ 2hrs
☒ 2hrs 30mins
☐ 3hrs
☐ Non face-to-face
☐Home
☐ Community Setting
☐ Other
Service Delivery Postcode
☐ Psycho-education
☐ Engages consumer in their care /treatment plan to support their recovery
☐ Liaison and support for patients, family, carers and other professionals
☐ Acceptance and Commitment Therapy (Mindfulness)
☐ Medication administration and management (including managing compliance)
☐ Liaison, networking, collaboration and managing referral to other services
☐ Advocacy
☐ Cognitive Behavioural Therapy
☐ Brief Solution Focused Therapy
☐ Managing co-morbidities
☐ Motivational interviewing
☐ Suicide prevention
☐ Joint sessions with GP and other health professionals
Intervention Type
Intervention Type - Other
HoNOS Tool Used
applicable)
HoNOS Total Score
applicable)
(if
☐HoNOSCA
☐HoNOS
☐ HoNOS65+
(if
Comments
lease note: It is a requirement that the Mental Health Nurse administer the relevant HoNOS Assessment with a patient
upon the initial session, every 90 days and upon discharge from the MHNIP.
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