Project Report Internet tool box for rural GPs to access mental health services information

Introduction: Rural GPs play a significant role in the mental health care of their patients. It is therefore crucial that they have access to reputable support and advice that enhances their existing knowledge. This article outlines a recent project initiated by the Australian rural Ballarat and District Division of General Practice (BDDGP) to develop and implement an online resource to facilitate local implementation and delivery of the ‘ Better Access to Mental Health Care ’ (BAMHC) program. This 12 month project was initiated in response to a request from local GPs for additional information about and support in using the BAMHC program. The project is the culmination of significant collaboration among key stakeholders that includes local GPs, GP advisors from BDDGP, BDDGP staff, and two University of Ballarat research centres (the Centre for Health Research and Practice, and the Centre for Electronic Commerce and Communication). This article documents the key stages involved in the project from initiation to implementation, and reports on the use of this resource 12 months after its launch. Method: The BDDGP represents 107 GPs and six GP registrars and covers a large rural/semi-rural area of 7300 km 2 and a catchment population of more than 120 000. The format and design of the project entailed four distinct but interrelated stages of development: (1) developing the program specifications and localising it to the BDDGP catchment; (2) constructing a decision-making support tool with 7 sequential steps comprising key questions and links to detailed answers; (3) developing and populating an online service directory of local allied health professionals; and (4) constructing the website for easy access and navigation for GPs and other service providers. Results: The website was publicly launched in December 2007 and is hosted by BDDGP. Since then it has received strong support.


Introduction
In 2006, the Australian Commonwealth Department of Health and Ageing released a mental health program entitled 'Better Access to Mental Health Care' (BAMHC) to improve and increase access for the Australian public to GPs, psychiatrists and allied mental healthcare professionals 1 . The scheme provides rebates through Medicare for: (i) appropriately trained and Medicare-registered allied mental health professionals providing psychological therapy and focused psychological strategies 2 ; and (ii) GPs offering mental health services to their patients (eg preparing a mental health care plan, GP mental healthcare consultation) 3 .
The introduction of BAMHC and the increased demand for service mapping and coordinated pathways from local GPs about BAMHC prompted the BDDGP to undertake a project, in collaboration with the University of Ballarat's Centre for Health Research and Practice (CHRP) and Centre for Electronic Commerce and Communication (CeCC), to facilitate the local implementation of BAMHC. The principal aim of the project was to provide GPs within the BDDGP catchment with information about BAMHC to assist them with decisions about treatment and referral for patients with mental health issues. The project objectives were to: 1. Develop a website outlining key information and locally relevant resources about BAMHC for GPs. 2. Develop an online decision support tool to assist GPs in making decisions and accessing resources under BAMHC. 3. Establish an online service directory consisting of local allied mental healthcare professionals who GPs may refer to under BAMHC.
Three key improvement measures were anticipated from this process: (i) increased GP knowledge of mental health services in the BDDGP catchment; (ii) enhanced access to allied mental health professionals; and (iii) a streamlined referral process between GPs and allied mental healthcare professionals.
The purpose of this article was to document the key stages involved in this project and to highlight an effective methodology for tailoring a larger, national program to meet the needs of a local group of health professionals. In doing so, the article documents the processes followed from initiation to implementation, and reports on the usage of this resource 12 months after its launch.

Setting
Located in Victoria, BDDGP represents 107 GPs and six GP registrars and covers 7300 km 2 . It has a catchment population of approximately 122 000 4 encompassing the towns of Ballarat, Daylesford, Creswick, Clunes, Skipton and Ballan. Given its rural geography, BDDGP was keen for this project to be developed as an online GP resource (hosted by the BDDGP website). This would address some of the resource access issues rural GPs face because a website can be accessed from home or office, is dynamic and readily maintainable, and provides a wide range of information in one place.

Key measures for improvement: a brief overview of the literature
In 2004/2005, 11% of Australians reportedly had a long-term mental or behavioural problem 5 . Current estimates suggest that the majority of mental health care in Australia is delivered in general practices and primary healthcare settings, with GPs providing up to 75% of mental health care to their patients 6 .
Given the significant role of GPs in primary mental health care, the provision of appropriate and useful support is imperative. Despite this, GPs face numerous barriers to providing mental health care to their patients including: insufficient training in mental health skills at undergraduate/registrar . These negative factors appear to be exacerbated in the rural practice setting. A recent study that examined barriers faced by rural GPs when providing mental health care to depressed patients included time constraints, treatment issues (eg non-responsiveness to antidepressants) and issues related to access to and communication with . While some of these concerns are addressed by BAMHC, there is still work to be done to ensure the smooth transfer of information, particularly at local level. General comments to BDDGP staff by GPs indicated a need for further information about BAMHC in the practice setting, and for greater access to appropriate national and local resources to streamline its use locally. A particular and repeated request was for a list of local allied mental health professionals to whom GPs could refer patients. The BDDGP's response was to initiate this project.

Method
The design and development of this online resource entailed four distinct but interrelated stages. Each stage focused on a key aspect of information essential to developing an informative and well integrated website, and was the culmination of significant collaboration among key stakeholders (BDDGP staff; local GPs, CHRP, CeCC and GP advisors [the GP advisors are local GPs, paid by BDDGP, who provided advice on a broad range of matters]) to ensure all aspects of the website were meaningful to and appropriate for its intended audience.
While an internet-based repository of information is not unusual, the 'tool box' was unique in that some features that were tailored to address the needs of local GPs were recognised as a result of the strong collaboration among and input by key stakeholders during each stage of the project.

Stage 1: program specification and localising it to the BDDGP catchment
This first stage involved identifying and collating relevant information about BAMHC to inform the online 'decision support tool'. Consequently, the internet site contains a wide range of primary and supplementary information about the BAMHC program which allows GPs (and practice nurses) to quickly access key documents in one place, rather than having to search and download information from other sites. All the information on the website was gathered from reliable sources to ensure consistency in quality and relevance. Information sources included the following key organizations: the Commonwealth Department of Health and Ageing; Australian General Practice Network; Australian Division of General Practice and other general practice divisions; and the Australian Psychological Society.

Stage 2: building the decision support tool
In Stage 2 the decision support tool was designed to assist GPs in making decisions and accessing appropriate resources for the early intervention and management of patients with a mental health disorder. A logical sequence of 7 steps was developed in close consultation with BAMHC information and BDDGP staff and GPs (Fig1). The information for each step was placed in a 'best fit' sequence that would most appropriately meet the informational requirements of GPs as they work through the BAMHC program during a patient consultation. Each step of the support tool consisted of key questions requiring Yes/No responses, which then transferred the user to a new page containing the required information.

Stage 3: compiling the online service directory
In Stage 3 a service directory was established that consisted of local allied mental health individuals (clinical psychologists, psychologists, occupational therapists and social workers) and psychiatrists eligible for Medicare rebates for services under BAMHC. This process initially required consulting telephone directories and relevant professional organisations. Following this, confirmation of contact details, qualifications, areas of specialty, gap fee, and eligibility for Medicare rebate was obtained from each listed service provider. When the service directory was launched it included 52 professionals and information about other organisations providing mental health services in the region.

Stage 4: developing the website
The physical development of the web-based tool was undertaken by CeCC in Stage 4. Key representatives from BDDGP, CHRP and CeCC consulted closely on the development and presentation of BAMHC content (including support tool and service directory) for the website.
The website's access times were tested at www.freespeedtest.com using a range of connections and locations. The site was found to provide response times well under acceptable thresholds (less than 2 seconds per average page load).
The final website is accessible through the 'Tool Box' mental health support icon on the BDDGP homepage.

Strategies for change
To enhance awareness, accessibility and usage of this website by local GPs, consultation between GPs and BDDGP staff occurred throughout the project. A number of strategies were also provided for encouraging awareness and change (both at the official launch and later when accessing the website). Regular email project updates to GPs by the BDDGP's mental health and GP wellbeing coordinator ensured the success of these change strategies.
In addition, all GPs in the BDDGP were invited to a 'piloting session' to familiarize themselves with the site. A total of six GPs attended, three of whom were BDDGP GP advisors or GP program advisors; however, only one had been involved in the early stages of the project. Feedback from the GPs at the piloting session helped 'fine tune' the support tool and service directory. Responses to a questionnaire showed the GPs agreed or strongly agreed that the content was appropriate, that the information would be useful in their practice setting, and that the information on the website would add to their knowledge about the BAMHC program. Additional written comments received included: 'Excellent idea', 'Good stuff', and 'Very good indeed'.
The final strategy for change was the official launch of the tool, and the website 'going live'. All GPs in the region, practice nurses, practice managers and other professionals representing regional health organisations were invited to attend the launch, which included a welcome and introduction to the tool by a local GP and BDDGP advisor, followed by the provision of background information and an orientation to the site, and audience questions. A total of 16 GPs, 10 practices nurses and two practice managers attended.

Uptake and sustained use of the website
Statistics compiled in the month after the website's launch were encouraging and showed an average 170 visits and that over 1600 pages of information were accessed. In the 12 months after the launch, strong use continued with over 2847 site visits and 11 500 pages accessed. An average of four pages were accessed on each visit. The value of the web tool is further endorsed by the number of repeat visitors. Forty percent of site visitors have previously visited, and the average length of each visit was 2 min, 33 seconds.
After the first 12 months of use it can be cautiously assumed that a significant proportion of visits to the website are made by GPs and allied mental health professionals. First, details about the website have not been released to the public (although the website is not password protected) and only local GPs and allied health professionals have been advised of its existence. Second, site statistics indicate approximately 50% of site visitors come directly from the BDDGP website, with the number from 'organic' sites (such as search engines) proportionately smaller. The pages of most interest to visitors are the home page, the referral template letter and then a selection of different stages in the tool. For example, almost 25% of visitors entering from the home page went directly to the service directory, while a further 14% went from the home page to the support tool (offering a template for the mental health care plan). Such navigation patterns suggest repeat visits by GPs. If GPs represent the significant proportion of site visitors, their understanding of BAMHC will be increasing, and this would flow on to improving patient treatment and referral decisions for mental health issues. However, confirmation of the proportion of GP visitors would require the collection of background information for each site user.
Further indication that the web tool is affecting change can be found in the receipt of email from allied mental health service providers listed in the service director, mostly to request minor changes to their entry. This occurs approximately monthly and suggests that these professionals recognise the importance of the website for GPs' onward allied-health referrals.
Positive written feedback from GPs (received at the launch and also via the feedback mechanism on the site) can be summarized by that received from two local GPs who indicated the web tool was useful in their practice and that its content was appropriate to their needs. One stated the website helped integrate the BAMHC into his/her practice and also reduced the time required to manage the BAMHC program when with a client, singling out the service directory as one of the best and most frequently used tools on the website. A staff member at a neighboring GP Division also gave positive feedback, demonstrating the value of this resource both to GPs and those who work closely with them.
In addition, recent unsolicited, anecdotal reports to the mental health and GP wellbeing coordinator at BDDGP from four GPs at two separate general practices indicated usage of the web tool. This confirms the relevance and benefit of the web tool 16 months after its launch.
Although this project was not designed to measure quality improvement, this could be considered when developing tool boxes in the future. However, the positive feedback and ongoing strong levels of access to the website provide indications that the tool box is meeting its objectives in helping to reduce GPs' barriers to accessing the literature and tools of mental health care.

Conclusions
Essential to the success of this website and its sustainability is close and continued monitoring and updating of the information it contains. Current feedback suggests the project and resultant website have been beneficial as both a conduit of information about the BAMHC program, and a resource and tool to assist GPs with patients presenting with mental illness.
Regular monitoring of the rate of access, and a formal, longitudinal evaluation approximately 2 years after the launch will provide a more objective measure of the success of this tool. However, initial results pave the way for considering the establishment of online tool boxes for Divisions of General Practice in related areas, such as chronic illness. Indeed, this website was developed to have the capacity to be replicated in other regions and specialty areas. However it would need to be ascertained that economies of scale and sustainability similar to this project could be achieved.
While the current project does not address the pressing rural issue of the lack of allied mental health providers, it does provide a tool that helps expand the service system, and also assists rural GPs by offering a localized online tool for accessing appropriate information.