Transcript for
Taking a team approach to managing children’s mental health in general practice

Narrator [00:00:02] Welcome to the Emerging Minds’ podcast.

Sophie Guy [00:00:08] This episode is one of a four part series that sits alongside the Emerging Minds e-learning course ‘A GP framework for child mental health assessment (5-12 years)’. The course looks at engagement skills, formulation, phases of a child mental health assessment, and the ongoing management of a child with mental health difficulties.

Sophie Guy [00:00:28] In today’s episode, we’re joined by Dr Matthew Ruhl, a GP from Queensland. Matt is a fellow of the Australian College of Rural and Remote Medicine and has advanced training in mental health along with a special interest in sexual health and addiction. He is currently the acting clinical lead for Kobi House, a sexual health clinic in Toowoomba. He joins the podcast series today to discuss the role of collaboration and a team-based approach to children’s mental health.

Sophie Guy [00:00:55] Hi, Matt. Welcome and thank you for joining me on the Emerging Minds’ podcast series.

Dr Matthew Ruhl [00:01:00] Thank you.

Sophie Guy [00:01:00] We are here today to have a conversation about the role of collaboration and a team-based approach to supporting children’s mental health. And to start this conversation off, I wondered if you could talk about what you see as the GPs role in management of a child following a child mental health assessment.

Dr Matthew Ruhl [00:01:21] I see our role as very multifaceted, both as an independent clinician as well as a a team coordinator. So obviously, during the assessment where we’re assessing, we’re taking history. Most importantly, we’re building a rapport with the child and their family. We’re examining, we’re  excluding other diagnoses. We might be part of the diagnostic process ourselves. We need to consider how to best support the child and the family in a recovery focussed way. And that can be including the support of other professionals, depending on our level of confidence and what the issue at hand is. But also rallying those that are already close to and supporting the child in their environment before we are made aware that an issue exists. Part of this too going onwards, is we assess the progress, look at onward referral, if not much is happening, or further referrals. Particularly too, helping to support and psychoeducate the family members and other members around the child. Never doubting that that sort of interaction is really important. People’s understanding of even simple conditions like depression and anxiety can be very variable and there can be a lot of hopelessness sometimes that oh, you know, my my child is unwell, that they’re never going to get better. It can be catastrophization that we can help alleviate. The other thing here, too, is that families operate as a unit. If the child is unwell, that can put a lot of stress on other family members and we may need to support them as well or encourage them to seek support from their own general practitioner.

Sophie Guy [00:02:56] I’m just thinking about this idea of the GP’s role in management. What’s perhaps in the plan for the child and the other allied health professionals that might sit around that, is there a sense of responsibility for the GPs to manage those things going forward for a child?

Dr Matthew Ruhl [00:03:13] I think so. We are set up in the community, as you know, we get spoken about as a bit of a gatekeeper and sometimes in a negative fashion, but more often in the positive that our job is to coordinate the care around any patient. And part of that is making sure that all the different members of the team are communicating with each other in the best interests of the patient, which in this case is a, is a child who may not be able to advocate for themselves as strongly as an adult patient may be able to.

Sophie Guy [00:03:43] And I was interested in what you referred to before about rallying the people around the child, could you talk a little bit more about what that looks like?

Dr Matthew Ruhl [00:03:51] Most kids have a number of people already supporting and looking out for them. I’m thinking here of day care, schools in particular. A classroom teacher at a primary school is spending several hours a day with a child. They see how they’re focussing. They see their attention. They see how they’re socially interacting with other individuals. They may have almost as much time or sometimes even more time with a particular child than their own parents will. So they’re a really essential person, both from a an evaluatory perspective of how things are going. But also in supporting that child to recover and do their best.

Sophie Guy [00:04:29] And how do you bring those people onboard? I might sound a bit ignorant here myself, but is it standard practice that a GP would reach out to a child’s teachers or educators as part of a mental health plan?

Dr Matthew Ruhl [00:04:43] It depends on the situation. Sometimes it’s not needed. Sometimes it’s not desirable based on the child or parents preference. But sometimes it’s very important, particularly where school might be part of the issue in the sense of bullying or absenteeism. In terms of how I’d reach out, usually I’d give a phone call with the consent of the child and the parents. Give a phone call to the school and try and connect with whoever’s most involved with the child. If it’s primary school, that tends to be the classroom teacher. They’re their primary contact, you know, has a strong pastoral role. In high school that might be somebody else, like a school nurse or a guidance counsellor who may not have had a lot of contact with the child so far, but may be able to play a stronger role.

Sophie Guy [00:05:30] Okay. And in your view, who are the key team members or stakeholders in a child’s life?

Dr Matthew Ruhl [00:05:36] The child themselves, we have to consider them in context of their family. Their parents or their caregivers and their siblings are going to be the very most key team members in their life. And I think we have to be very aware here, you know, that the nuclear family is no longer the norm. A lot of different family situations exist. And so I tend to talk to the child initially, and I’m a really big fan of building a genogram. Looking at who has strong relationships with the child and what types of relationships they are, positive or negative. Other family members slightly on the periphery, like grandparents, aunties, uncles, looking at kinship care situations. And as I’ve already mentioned, school, day care, after school, or extracurricular events. Sometimes children may already have established relationships with other health care providers as well. So I see that as they’re some of the key team members in a child’s life.

Sophie Guy [00:06:38] And then how do you work with these team members? What does that look like?

Dr Matthew Ruhl [00:06:42] Trying to formulate an easy and streamlined way of contact, I think is important. As a GP, time is always a bit of a constraint and we don’t have a lot of time outside of direct patient contact to be able to be making lots of phone calls or sending a lot of communications. So trying to keep the child at the centre of everything. I try and have one sort of key contact person from each group. So that might be, you know, one of the parents. One single person in a school or a day care. I do occasionally look at using family meetings for important education and updates. Now, there are some Medicare item numbers associated with that, depending on the length of time. So like the group therapy items, the 170, 171, 172 series. If it’s more than an hour and you’ve got two to four or more people, they can be a good item number to use if you’ve got an intervention with some specific outcomes there. And that, like I said, psychoeducation can be a really important one there or formulating a group plan with the family as to how to approach a particular issue.

Sophie Guy [00:07:51] Right. And what kinds of things get in the way of being able to work like this and establish these relationships with the people in a child’s life?

Dr Matthew Ruhl [00:08:02] I think time is is the biggest issue. Time, and if it all gets a little bit out of hand with too many people wanting to have direct contact with yourself. And that’s why, like I said, I tend to aim for one key family member who can distribute information in each group. And it’s their sort of role and responsibility to distribute information further. Like if other school individuals are going to play a role in the child’s ongoing care, it’s still useful to have one person whose job is to communicate with me and distribute that information onwards. And if it’s really necessary, like if somebody really needs a lot of clarification or they’re playing a bigger role, that’s fine. But yeah a lot of these conversations obviously, you know, without private billing, you are kind of doing off your own back, financially, and that becomes a bit complex. So sort of time/money is one barrier as well as just trying to coordinate the team together, which in some children’s lives can get pretty complex. They do need a lot of input from a lot of different individuals and it becomes a bit like a many headed hydra.

Sophie Guy [00:09:08] And is anything more that you could add to working with the benefits schedule? Is there anything else you could add, you know, suggestions around how you can work with that to do this team-based approach here.

Dr Matthew Ruhl [00:09:19] One of the other item numbers or item group numbers I use is looking at case conferences. These are only applicable in some situations. So the patient themself. So in this case, the child doesn’t need to be present, but they or their parent must consent to case conferences occurring. Case conferences can be face-to-face, phone, or video conference. You need a minimum of three people. That can be yourself as one of them. A teacher. You might have a psychologist or a psychiatrist involved. And the client themselves needs a chronic condition and in this case, that means has been present or is likely to be present for more than six months. [Okay.] The numbers for case conferences are the 735, -39, and -34 series, for those interested in having a bit of a detailed look at those in the schedule.

Sophie Guy [00:10:12] OK, great. Now the next question is around what is the role of the GP in referring children as part of the Better Access pathway?

Dr Matthew Ruhl [00:10:23] So the Better Access pathway obviously is one of the methods of accessing psychological support for a child or for any individual. That has a few components which fall onto the GP. One of the most important of which is the preparation of the mental health treatment plan, sometimes called a care plan. Now there are a number of templates available to smooth this process. To ensure that we’re getting as good a document as possible to be able to support the child. But also to make sure that we’re covering all the essential areas once again under Medicare to ensure we’re not fraudulently billing an item number.

Dr Matthew Ruhl [00:11:00] The other thing that’s needed after this mental health treatment plan is formulated is a letter of referral to an appropriate psychologist. And then follow up from this. The mental health treatment plan sometimes gets done and then filed away and never looked at again. It’s actually supposed to be a living document. And so as the child works with a psychologist, hopefully, you know, to their benefit, we’re getting feedback from the psychologist and we’re helping to revise this mental health treatment plan and ensure that everything’s heading in the right direction. Knowing that a lot of individuals, too, like it takes a bit of time to find the right psychologist. The first one or two sessions might not turn out to be useful to the child, and it may be worth then getting them back. Discussing that that, unfortunately, is a bit of a normal step in the pathway sometimes. And looking at finding somebody else who they might work better with.

Sophie Guy [00:11:55] How do you support a family around that? Because it’s very true that it can take time to find someone that is helpful and you feel comfortable with and, how do you manage that? Because you have sort of a limited number of sessions that you can have as well.

Dr Matthew Ruhl [00:12:11] Yeah, that that 10 session limit, which obviously under covid some people in some areas have had access to a few more. The 10 sessions does get in the way of things a bit. And I do set things up with the family to begin with, noting that it may take time to find somebody that everyone can trust and get on with. And that could mean that at some point that some ongoing sessions may need to be financed privately. And keeping in mind too, Better Access provides a Medicare rebate for psychology sessions but a lot of psychologists still have a gap fee above that. Working from a rural area, I sometimes use some of the online services. One particular one I’ve liked in the past is LYSN, L-Y-S-N. LYSN has a really nice advantage that while there’s a small booking fee for each appointment, they also offer a short 20 minute meet and greet appointment with individual psychologists. So you get to browse a list of profiles of psychologists who have special interest areas that may suit your child and you have that 20 minute little meet and greet, which I think from memory costs about $20. That doesn’t use up one of those longer sessions then under the Better Access pathway.

Sophie Guy [00:13:29] Okay, that sounds like a really good idea. You talked about the idea of the mental health treatment plan, that it works best as a living document. Could you talk a little bit more about that and how you ensure that it stays a living document?

Dr Matthew Ruhl [00:13:43] Obviously, you know, most of us are using an electronic health care records system in our practices. It does make it easier to be able to pull up the document and alter it as things change. All of the mental health treatment plans have a list of goals and outcomes, and that’s the really important part to be revising. I don’t make any usual set time periods to revise mental health treatment plan except for the first revision, which I try and do somewhere around the six to eight week after it’s made period. At that point, hopefully the person has made contact with a psychologist and has had at least one appointment and we can sort of put our feelers out as towards if it’s going to go well. At other times of the year, you know, like when you get written information back from a psychologist, that can be a good time to revise the treatment plan. Because under the Better Access pathway, those 10 sessions, obviously you can break them up in to blocks. Sometimes you can specifically release the first six at once and then four afterwards. Or five and five. In some cases, it can be useful to release only two at the very beginning so that you’re ensuring that after two sessions you’re getting some written communication back from the psychologist to, once again test the waters, from their opinion, how things are going with the client. And all of these can be a good trigger to revise. There are some, once again, item numbers that can be useful to revise a mental health treatment plan like 2712. But you don’t need to use a particular item number. And for the review and release of further sessions up to that 10 total per calendar year, you don’t have to bill a particular number or not. It can be just a regular review where you happen to fit in a bit of a discussion about how things are going.

Sophie Guy [00:15:41] And you said that you like to ensure that you do have the child and the family back after about six to eight weeks. Do you make sure that appointments booked before they leave, or do you do leave it to the family to book that in?

Dr Matthew Ruhl [00:15:55] The reality is usually I like to see people more often than that. And so that tends to be a, you know, trying to see people every two to three weeks, maybe even weekly, depending on the severity of what’s going on. So usually that six to eight week review of the actual mental health treatment plan happens in one of these regular booked appointments. But if not, if it’s with some clients, I might book that on their behalf, with their permission, or give them a phone call after, say, four to six weeks and encourage them to book that next review.

Sophie Guy [00:16:30] Okay, and we did touch on this earlier but how can GPs work with schools in a more collaborative way?

Dr Matthew Ruhl [00:16:37] I think it’s useful to have one contact person when you’re working with a school. Schools obviously have their own needs and agendas compared to yourself in the healthcare system and parents within the family unit. It’s useful to encourage parents to develop a relationship with the different stakeholders in the school as well. Like I said, the classroom teacher can be a really good point of contact, particularly in a primary school situation. But who you get in contact with may be very much dependent on the situation and what sort of needs the child has. In a high school that might be the school nurse may be a really good person because they have a good level of anonymity as well. In that, a high school student can attend the school nurse and there’s not a lot of of documentation or feedback to other members of the school, which may be really good. That discrete environment for a student to be able to talk with somebody just slightly offset from the rest of the school hierarchy. Guidance counsellors can be helpful, particularly where there’s a lot of effect on their learning. In smaller schools, the principal or deputy principal may be your best contact, who you know, in some of the smaller primary schools in rural areas, too, might be the classroom teacher for the child in question.

Dr Matthew Ruhl [00:17:52] I suppose this has to be taken in context of who the child is, what their needs are, what the school is and what size it is and who’s going to be the best person or people to talk to. Some of this can be verbal over the phone. With consent too, sometimes I find it’s useful to have a bit of an email stream going as things need to be updated backwards and forwards. And keeping in mind who’s in that email and what sort of information they should and shouldn’t be privy to. Email obviously is not the most secure of methods, and that’s why I did just state that consent from the client and/or their parents is really important there. Consideration, if you’ve got the ability to encrypt the contents of that email that it can be useful for some small updates.

Sophie Guy [00:18:40] Sure. And I think finally, just to touch on whether you have any final sort of advice or guidance for GPs listening to this who are wanting to collaborate with the team around their child but perhaps haven’t really gotten a process for doing that.

Dr Matthew Ruhl [00:18:57] So I think part of this is looking at some of your regular review appointments. Consider that they might be used instead as a bit of an update or a team collaboration. You know, a lot of your appointments, you may want to have the child by themselves. But it’s still useful to have some appointments with the parent sitting in, at least for the tail end of the appointment, to look at a bit of an update,. A bit of a view to where we’re moving forward and what the goals are. And if any of those goals are changing. As well as looking at the collateral history that can be gathered through parents, as well as, like I mentioned, school and other stakeholders. It’s looking at what sort of communication methods are going to be most convenient and useful to you as a GP, plus the family, the school and whoever else is involved. I think looking a little bit around some of the item numbers that can be useful, whether you’re privately billing, mixed, or bulk billing. We have to be appropriately remunerated for the work that we’re doing and the MBS item numbers obviously allow the patient to get the best rebate possible, whatever your fee structure is. But also the use of the mental health treatment plan as a living document and looking at any case conferences and family meetings that you can supplement that with to help everyone work together in a streamlined way. And so everyone knows what they’re actually doing at any one particular time.

Sophie Guy [00:20:24] Great. Well, we’ve covered all the questions that we had planned to today, and you’ve given a lot of really helpful information. So thank you very much for your time today, Matt.

Dr Matthew Ruhl [00:20:35] Thank you.

Narrator [00:20:37] Visit our website at www.emergingminds.com.au to access a range of resources to assist your practice. Brought to you by the National Workforce Centre for Child Mental Health led by Emerging Minds. The National Workforce Centre for Child Mental Health is funded by the Australian Government Department of Health under the National Support for Child and Youth Mental Health Program.