 Okay. Good evening, everybody. Welcome to the – I think we're going to have nearly 800 members that participants tonight who have joined us for tonight's webinar and also all the viewers who might be watching this as a subsequent podcast. We just opened up Mental Health Professionals Network which is to acknowledge the traditional custodians of the many lands across Australia upon which our webinar presenters and participants are all located. We wish to pay respect to the elders past, present and emerging from the memories, the traditions, the culture and the hopes of all Indigenous Australians. My name is Dr Conrad Cunger. I'm a private general practitioner in Crossapine in North Queensland and I'll be your facilitator for tonight's session. We've participated in a few of these, so this is really a very interesting topic for us in that this is all about not just the topic and the content of what we deliver in mental health care, but more an exciting initiative on how we might actually be able to make that better happen. So we're really glad to see all that part of that. We're also very, very pleased tonight to have some excellent panelists, as always, for such an interesting topic. So we're not going to go over the full bios. It's actually a bit bigger than we used to be, but we welcome tonight Linda Swan from the Department of Health. Dr David Walker, who's a rural general from Longreach in Western Queensland. Jacinta Bell, who's an occupational therapist working in mental health care. Lauren Campbell, a psychologist in private practice. And Julianne Y, a social worker who also practices a lot of mental health care in the telehealth space. So we certainly are having to remember that we currently make these sessions happen through the funding of the Department of Health. And we acknowledge and thank them for their contribution. So we ask everybody just to be mindful of the ground rules which we have with our webinar sessions. We really want to make sure that everybody, not only those who are live, but also those who are watching afterwards are able to really get the most out of these events. So we just ask that everybody consider the following ground rules. Just remember that even though we're maybe on our own and isolated from each other, we are in a virtual space. So just be mindful of and be respectful of what other panelists and participants may be contributing. Remember that we're all trying to benefit from this as well as we can. We encourage you to use the open chat tab, which you'll find at the bottom right hand corner of your screen. So you can have the opportunity there to include in questions, which you might want to have us to answer. But please try to make sure that you keep those comments brief and on topic. That's going to give the best chance of covering through them. And if there actually are any problems that you're having with technical assistance, you'll find the technical help down there as well. If you can't find an answer in that, dial 1-800-291-863 if you're not able to get any joy with that one. So our learning outcomes for this evening's webinar, we'd hope that by having a talk through all these telehealth issues, I relate to rural and remote participation. This webinar is going to assist participants to outline how these new telehealth measures will provide improved access to psychological services in rural and remote areas. We hope that you'll better be able to recognise appropriate times to utilise these new telehealth measures for rural and remote clients. And that you might be able to identify some strategies that you might be able to use in your practice to implement these symptoms to hopefully improve the referrals for clients eligible for these telehealth systems. So we're going to open up with the other, that's effectively from our Department of Health colleague. So Linda Swan, over to you. Thanks Conrad. Look, I'm here tonight to introduce the new telehealth measure to improve access to psychological services in rural and remote patients. Which commences in about two weeks. I'm just going to provide a really brief description about what's changing. I'm going to summarise patient eligibility for the new items and who can provide advice on who can deliver those new items. And then give a little bit of information about where to get more information. So the Better Access to Psychologists, Psychiatrists, General Practitioners through the Medicare Benefit Schedule, otherwise known as Better Access Initiative, is available to patients with diagnosed mental disorder who benefit from a structured approach to managing their treatment. It was introduced in 2006 to try and lift the treatment rates for people with common disorders like depression and anxiety. It has been really successful and demand continues to grow basically every year. However, we do know that a scarcity of mental health professionals in rural and remote areas of Australia means that for some people accessing services requires significant travel time and being away from family or work. Or it means that they can't access services at all. So from the 1st of November, eligible patients are going to be able to access our mental health treatment through video conferencing, making mental health services easier and more convenient. So it's important to understand that this is really just a new way of accessing the services that currently exist. So a lot of the rules and requirements around Better Access remain the same. There will still be annual limits of 10 individual and 10 group sessions. The rebates for the telehealth items will be the same as the current face-to-face items. And professionals can continue to sort of determine their fees and charge co-payments if required and those sorts of things won't be changing at all. So what is changing? Eligible patients in rural and remote locations can access up to seven individual and seven group sessions per calendar year via video conferencing. Patients can access the balance of their annual sessions face-to-face. The other important thing to understand about the measure is that one of the first four consultations must be delivered face-to-face and that's to facilitate the personal connection and therapeutic relationship between the patient and the practitioner. We encourage practitioners to really use their clinical judgment as to whether this option is appropriate for their patients. And to understand that for a telehealth consultation to be eligible for the MBS rebate, then it needs to have both an audio and a visual link between the patient and the practitioner. So no sort of telephone calls or texting kind of services. The Australian government doesn't mandate what technology is used to conduct the consultation and encourage practitioners to negotiate that with the patient, ensuring that whatever they use is reliable and secure. And there will be new item numbers introduced for the telehealth items that can be used in conjunction with the existing better access face-to-face items. So for those eligible, patient eligibility basically mirrors what is in place now for better access. In addition, patients must be in a rural and remote location. So for this measure we're using the Monash Modified Model as the classification system and patients that live in regions 4 to 7 can access the new telehealth items. The Department of Health does have, oh sorry, something just jumped ahead there. And patients need to be at least 15 kilometres by road from the practitioner at the time of the consultation. Services can't be delivered to patients admitted to hospital or an emergency department. And on that slide you can see there's a link to a page on the department's website where you can go in and just search for your location and see if it is in a Monash Modified Model 4 to 7 region. So in terms of who can deliver the new services, again it basically is built on the existing better access initiatives. So anyone that can currently deliver a better access service can deliver the new telehealth services. And we'll note that additional telehealth items have not been included in the NDS for general practitioners. Further guidelines on the measure including who can deliver it and are available on the Department of Health website. And we'll point out that the Australian Psychological Society is developing resources to support practitioners to consider a range of issues including whether telehealth is the right option for their clients and how to deliver services safely and effectively. And those resources will be coming available over the coming weeks. So we also have a frequently asked question document that we've updated and put on our website today. We'll continue to update that as we get questions and feedback. We encourage everyone to go and have a look at the guidelines and the FAQ on the department's website. And if you have any other comments or questions or feedback, happy for you to provide that through the feedback tab on the website. So thank you. That input and thanks for participating in tonight's session. So it's great to know about these initiatives and the technical points that go with them. But as clinicians we need to know how this actually relates to what we're doing. So again we'll just briefly recap on Warren's story. Hopefully you've all had a chance to prove him. So Warren's a 58 year old male who's been a motel operator in a rural town some time. He and his wife Karen, who's 55 years old, they've been working busy there raising their family. But certainly noticing that there's been increased stresses going on lately. He's Warren starting to use a bit more alcohol, not really sleeping all that well. He's very fatigued, it's snappy and irritable. And so Warren's finally taken the suggestion that he should actually come in and see the family GP. So we're going to now hand over to the first of our panel, Dr. David Walker from Longridge. David, as the GP who might be looking after Warren, what would be your input into his care? Thank you Conrad and thanks for the chance to present tonight and welcome everybody. It's great to be presenting. I think Warren's case is one that probably most of us can relate to. I find him fascinating. And I think most of us would have a patient like this who presents at a point in their life where things aren't really going right. And I think the advantage we have as GPs is that we really have the longitudinal relationship with patients and the kind of background knowledge of their situation, their family, we might have treated their kids. Now all those things allow us to forge ahead from this point in time to treat Warren in the best way. I think it's quite likely that we might have seen warning signs in Warren as we've treated him over the years. Perhaps he's dropped off our radar. Perhaps he's someone who we haven't seen for a while. And the fact that he's presented is actually selling it to himself. But I think, as I said, understanding the context in which he works, he's probably very busy. He's working really long hours. His income is probably very seasonal if he's in a tourist area. And really kind of getting an understanding of what makes Warren tick. I think it's also important if I was in this situation is to actually exclude organic causes for his presentation. Make sure there isn't actually anything obvious, any other obvious reason as to why he's presented today and why he's feeling fatigued and lethargic and snappy. And really when I'm faced with this, I really like to see the whole person. Who is Warren? What makes him tick? What's going on in his life? And what are the medical conditions which he faces? From a mental health point of view, I guess if we have excluded organic things then we're really in a position where to allow him access to the Better Access program and we do need to make a mental health diagnosis. We could talk all night about the validity of different mental health diagnoses and we won't tonight. But certainly when you give people a diagnosis, you have to address concerns about stigma and what his understanding of what getting a mental health diagnosis means. And I think that's really important because it really helps with any ongoing therapy for him to know why you're making a judgement and what's going to happen from here. He's going to have a thousand questions going through his head and it's our job to start addressing those. I really, really try to put away my script pad and not jump to the conclusion that everything someone presents with from a mental health point of view needs medications. You know, I'm not trying to teach any of this to suckies because I think most of us are sensible like that these days. But I really get to the point where we want to discuss what are his other options. You know, what are the things I can offer him? And in my town, his options are really limited. So what else is around? You know, how close are your neighbouring towns? Are there face-to-face options that he'd prefer to use? Are there digital options? I'm sure a lot of us are aware that there's lots of digital platforms these days that both psychologists, mediators are not other forms that people can use. And that really appeals to some people, things that they can do from their own home. And the exciting thing that we're discussing tonight is, is he eligible and would he be interested in using telehealth to access an allied health practitioner? So from a practical point of view, to allow him to get access, we do have to do up a mental health treatment plan. And the paperwork is the paperwork. I really enjoy kind of talking to the patients where they see their treatment going, what their goals are and then do up a referral. The telehealth is very foreign to some people and I think discussing the practicalities and the logistics of what it might actually entail, you know, with regards to a computer and having enough bandwidth. I know it's a big issue in rural areas. A lot of my patients have very, very limited data allowances and very limited access to the internet. So I think discussing the practicalities and it might actually preclude him from doing this in the first place. And then at the point deciding, well, who's the best, the best person for that to see? And I'll put psychologists there, but obviously as we all know, that might be any allied health practitioner that you think is the right person for Warren in this case. I did note, and not to be a negative now, but I did note that general practitioners who do provide focus psychological strategies are exempt from using this scheme, which I personally think is a shame, but it is what it is at the moment. And Medicare rebates are available to GPs to sit in on telehealth consults. That's a little bit different to some of them that you might be familiar with. Again, I think it would be useful to be able to sit in on telehealth consult just to help case coordinate with whoever you're referring them to. So whether that's several sessions in, you actually have a catch up on finding out what's going on and what the plan is. The other point that's struck me is that certainly in Queensland, the patient travel subsidy scheme doesn't cover patients just travel to see allied health. So it's really important, I think, to check your local rules as to whether the patient will get some patient travel assistance to go and see an allied health practitioner for those visits that aren't that they need to see face-to-face. I think that's my thoughts on one unless you have a question for me. And I think David, it's always great to see that a very practical approach and good for all of us to remember that we shouldn't always be jumping to medications that the first line every time somebody in distress comes through the door. But you're absolutely right. There are a lot of practical issues that go around using this type of care and this type of initiative. Jacinta Bell, occupational therapist working in a lot of mental health care provision, why telly health, what might you bring to Warren's care? Thanks, Conrad. Well, first of all I would just want to make sure that telly health was the most appropriate way to deliver services to Warren. Certainly he would meet the criteria for the Better Access program. He's living in a rural area where the closest psychological service is 50 kilometres away. He's concerned about stigma and he's very time limited. At this stage with the information we have there doesn't seem to be any acute risk. And really I just want to have a discussion with Warren beforehand and ask is he willing to engage and to travel for at least one appointment face to face. From my perspective I work and operate from Capital City so that would be something you would need to think about. Also does Warren have access to reliable and affordable technology that's going to be suitable for teleconference? And one thing that's probably less related to telly health but more related to the profession of occupational therapy is that being mental health occupational therapy service are we the best available mental health provider to meet Warren's needs? And is the GP willing to refer to an occupational therapist who is endorsed to provide focused psychological strategies because often I find that they're not aware that, not always aware that occupational therapists do provide these services. So next I really would want to be very concerned about managing risk. It's probably one of the things that's most essential when providing services via telly health. You have to think about what would happen if Warren expressed suicidal ideation during your video consult or left the consult abruptly or didn't present for the consult at all. My preference would be to have the initial consult through a face-to-face consultation simply so we can develop the therapeutic relationship. I can conduct a thorough risk assessment, develop a contingency or crisis plan if necessary and then agree to reasonable boundaries for the provision of services. So for example we might set up an agreement that if Warren doesn't respond to the video conference I will call his phone and if he doesn't answer the phone I will call his wife's phone. It's really important also to be aware of all the relevant services available in Warren's area so we can build this into the plan if necessary. So what kind of mental health services are there? Would there be access to emergency services like ambulance and GP? As I'm based in the city the initial consult can often be coordinated with other specialist medical appointments or reasons to travel to the city such as collecting supplies. So we would do the initial consult face-to-face. We agree on a treatment plan, a crisis plan and contingencies and I would write that to the GP at that point about lining the details. That might also warrant a phone call. Then we would have subsequent appointments via video conference at least initially. This is where we need to just keep in mind privacy. We're using a platform that has end-to-end encryption. Warren would need to have a quiet space where he's comfortable to sit for an hour or so and able to talk unencumbered. So with a door that closes and no other people in the room it's best if the computer is hardwired to the modem rather than on a wireless connection as this can cause a lot of problems. And the clinicians would need to be set up in the same way. Clinicians will also need to be presented professionally and the environment around you should look professional. So you really need to be in an office sort of environment with good light dressed in appropriate clothing. It's really good idea to test any technology before the first teleconference to make sure it works properly and also to have a plan of what to do if the internet connection is no good or drops out. So for example one thing I've done before is turned the sound off on the video conference over the internet and just had the video via the internet and spoken over the phone when the connection is poor. It's ideal if Warren has access to a secure platform for sending documents, a printer and a scanner or a fax so that you can send through any worksheets, reading questionnaires that Warren can do and then send back to you. Post tends to be too slow so this is to happen in a timely manner. It's difficult to write on a whiteboard or show things on a piece of paper during consultations so it's much better to send these things through a secure platform before or after the appointment. While engaging via video conference it really helps to position the webcam and the video of the client at eye level so it looks as though you're making eye contact and talking to Warren during the consultation and of course using all of your usual active listening skills. Remember that just as you do with your regular clients to be punctual to let Warren know if you're running late so he's not sitting at the computer waiting for you for a long time. And I prefer it myself to be the person who initiates the teleconference rather than the client initiating it. At the completion of the six sessions then I would write back to the GP about the progress and or call them and offer recommendations. Just from an OT perspective very briefly, we would really be looking at enabling occupational participation so helping Warren to do the things he wants to do and needs to do in his life and overcoming barriers to doing that. And as you can see there listed some of the methods we might go about using to do that such as psychoeducation, motivational interviewing, goal-setting, sleep hygiene, activity scheduling, problem solving and stress management. Thank you. Thanks Jacinta. That's marvelous. And look, it seems like a lot to get through but really having a step-by-step process like that that really can break down a lot of these hurdles that we seem to face. Of course those of us who are logged on tonight are well familiar with the use of telehealth and internet technology so hopefully we've got a little bit of a head start. Warren Campbell as a private psychologist practicing out of Hamilton in Western Victoria, I'd imagine that you'd have plenty of occasions where you're needing to make contact with patients who are coming from vast distances. How do you think you might be applying telehealth into the care of a patient like Warren? Thanks Conrad. Yes. Because we're fairly isolated in the Western District of Victoria and it's four hours to Melbourne and six hours to Adelaide we do find that we need access to other technology. Recently a client was referred who lives 200 kilometres away so she had a 400 kilometre round trip. So with the referral of Warren for example is the via David's mental health care plan and better access telehealth. We could certainly put that into practice for everyone's benefit if Warren is happy to do so. The initial consultation I would see is being in my consulting rooms which I share with four physiotherapists, a podiatrist and a dentist. So in fact if Warren turns up at the office he's likely to be seeing a physiotherapist really and no one would know. I would encourage his support person, his wife Karen to come because she was the one who observed his character at Dick's at home and encouraged him to see David and also to be a support person there and to drive him home because he might not feel comfortable then after the consult to drive home. We introduced telehealth as David has already touched on it or mentioned it with Warren. So to clarify the advantages of using telehealth with him if he is happy to do so with the seven subsequent consultations arranged by telehealth on an agreed technology platform with Warren's consent of course that would reduce the first from the cost of the 100 kilometres around trip each time and that would have been ten consultations perhaps reduce his time away from work and increase his perceived confidentiality in a small community. So he wouldn't be having to come to the room very often he wouldn't have to park outside and someone would see him coming maybe to see a psychologist. I've established ground rules with him and Jacinta has certainly gone through these in great detail so I'll just read through quite quickly. Warren needs to be aware to commit to the appointment time as if he was coming into the consulting room so it's not oh just a minute I've got a phone call coming in or whatever he would need to come and be present. It's for him to specify a particular location in the home or office and maybe the home would be better than the office where he will not be interrupted or overheard. Check that your client or Warren in this case has had experience with Geico FaceTime which is what I would tend to use and with children of that age 22, 20 and 18 I'd be surprised if you hadn't used most of those platforms. Recently I had a client who hadn't used FaceTime but she was quite keen to have a try and so I suggested she practice with family or friends. I tend to ring the client at the specified time almost exactly. The length of the appointment time is still much the same as it would be in the office 50 minutes to one hour and Jacinta was saying about using your listening skills very much so but also you can actually see a lot from the visuals. You can see the client is anxious. Well hopefully not from just using the video conferencing but that they look hired that things are not going well for them so it's actually a really good thing to do to use the visual. As far as the therapeutic process again I like to start with psychoeducation and relating the depression anxiety to sleep and sleep is a very big deal. If you don't sleep well really much of life is not good. I tend to use acceptance and commitment therapy a lot and to encourage Warren in this case to accept the situation has occurred and for him to figure out what's important which I know that Julianne is going to go into in more detail. I like to get clients to focus on positive anchors to divert their negative thoughts and maybe three positive anchors so he can think of those things and enjoy his thoughts throughout the day and not just focus on the negative. Lots of things pop up to consider for example finances effective Airbnb on his business right through to does he have any past trauma that's as worried to him and he's of the age where he can't contain that trauma. A lot of older people the trauma just pops out at them and they really have to deal with it at that point. To try to empower Warren as a client to focus on an area that can be changed or improved for him to have a choice of what to have a look at first and provide feedback to David and the rest of the allied health team if Warren has other workers also working with him of course with his permission. So that's me. Thank you. Wonderful, Warren and thanks. I noticed that a lot of you mentioned Skype and FaceTime as two of the platforms available. Some of our other participants are already coming up with suggestions of their own. Zoom and VC, I'm not going to pretend that I'm a failure with all of those but I'm certain that there are a lot of appropriate platforms available out there. Yes some of them may require a subscription but I would hope that the assurances regarding security and privacy might make that well worthwhile. We're now going to move on to the thoughts of our panel and we welcome Julianne White. Julianne is a social worker practicing in mental health and she's working out of Kaurawa in southern New South Wales. Julianne, I wonder what perspective you might bring to Warren's care. Okay, Julianne's just dropped out there for the moment. That's okay. So what we might do there is we might actually just revisit at that point, Lauren. So you mentioned some of the modalities that do you. The acceptance commitment therapy is being one of those. Lauren, I wonder how do you decide about what would be the approach? Do we actually know that for all of these practical advantages that telehealth has got, do we actually know that there's any sort of research that's been done to say are these services just as effective as using face-to-face consultation? Yes, they have seen luckily, well, our good fortune that they've been some Australian studies and Susan Simpson at the University of South Australia seems to be the one who's done large research with a variety of colleagues. She's published three papers in the last few years and she indicates and I think her last paper was published in the Australian Psychologist in 2015, issue 50, but she said the outcomes of the video conferencing are equivalent to face-to-face therapies across a range of groups, both using standardised assessment and evidence-based therapies. There appears to be a high level of satisfaction and therapeutic rapport with clients. So, yes, it's very positive feedback overall. And otherwise, with any therapeutic interaction, it is that the strengths of that are that it's a circuitous relationship, I guess, which really makes the crux fair to it. Some of our other questions coming through, just talking about the services that are available and also about the billing, we will certainly make sure that we come back and we might be able to address a few of those questions later on. And certainly, yes, the questions about the rebates is all of the rebates, as Linda had mentioned earlier, are equivalent to the current services or the current fees which are applicable, that these aren't as specifically rebated item separate to the types of sessions which you'd be providing already to a patient referred to you under a mental health treatment plan. Do we have Julianne available yet? Okay, that's all right. Well, we might just come back up there, David. So we'd mentioned previously that, David, that for a lot of providers who are a lot of GPs who might not be too familiar with this modality, do we actually have any directories available for how the current GPs might be able to find mental health providers who are using this program? When I heard about this, I think a lot of us who work really, and probably in urban areas too, develop kind of tried and true pathways to who we refer people to, not just with regards to mental health, so probably all our specialties. But with the advent of these new item numbers, I did look and I noticed that most of the, all of the professional organisations have now got online directories. To use the psychologists, for example, the Australian Psychological Society, if you Google BelieveInChange.com, you'll find their website. You can look up and try to find a psychologist. I'm not sure how totally inclusive it is, but it's certainly a very practical step in the right direction, because it can be a very time-consuming process to try to track somebody down. The other alternative would be to, and why I use this for certain specialties, is to actually task the patients to do some research themselves. Find someone who, you know, you can find a lot about people. A lot of these people have got profiles. Find someone who they think would suit themselves and then refer. So I really try to put some of the legwork back onto the patients. Thanks, Lennie. Lennie, we've got Julie Ann back. Julie Ann, are you happy to come in on what the space that you might bring as a social worker working in? Yeah, look, thank you so much and thank you for being patient. I'm sorry about all that technical issues. And I'm really conscious of what other people have said about the technical side of going into telehealth and also appreciating David's contribution as the GP. But as a social worker looking at this and what I'm going to do is look at some of these therapeutic approaches that people might take. And so we'd actually look at a person in an environment approach. We'd actually look at his broader social networking, things that are working well in his life as well as not be looking so well. Perhaps even looking at some of the more generalized aspects of his family and contacts and support to his family. As a social worker, we place the person separate from the problem, looking at the problems that are external to him or internal to him, looking at a biological and psychological and sociological assessment for Warren and his family. And looking at some of the medical issues like David has mentioned, fatigue, sleep age, knowledge and skills around sleep hygiene. Some of his psychological issues around his frustration, particularly grief and loss, around perceived beliefs that he might have about himself as a businessman and a person with status in the community, looking at his values, his coping mechanisms, styles and how he actually uses alcohol and other means to manage his worry like that some of these frustrations move. Then we'd actually look at his expectations, his finances, his perception of the problems and other people's perception of the problems. And we'll also talk to him about difficulties he might have accessing other support in helping his community. And like the other presenters have said, I think having a first initial session face-to-face could be really useful for Warren. Just to actually be able to go over what might be the benefits and expectations from him as to what might be delivered from telehealth as well as his face-to-face sessions. Because as Jacinta and Belinda have both mentioned, there's quite a few difficulties in rural communities providing really good, effective and timely telehealth services to people. So I think it's really good to have some really good structured approaches to what we could offer Warren. I'm really mindful too that he's very time-poor and really putting, you know, part of his problem is putting time into his business so we don't want to actually add to the burden any further. And I think when we're actually offering telehealth we're really mindful of those micro-skills that we use because we don't have those out-of-queues that we've got when we're sitting opposite a person. So very mindful of paraphrasing, summarising and also looking at facial expressions. And I love the way that Jacinta talked about, how she holds your eyes when you're looking at a camera so that the client really feels that they are listened to. And I think that's absolutely critical in providing continuity of therapy between face-to-face and telehealth. So going back into some more of the therapy approaches, you're really looking at the hierarchy of the problem for him, but quite a few out there, you know, with his frustrations, his schemings, his beliefs. And actually really trying to help him unpack how he's tried to fix the problem in the past is a really clever man. I think we've got to really acknowledge his strengths and his skills that he's had in the past. I'm just going to do something here technical to unmute that. And then also to use his family member and look at other systems involved in his life. Got to start with some short-term goals that's really achievable for him, very mindful of the time that he wants to spend on actually looking at solutions. Really mindful too that, you know, a lot of his frustrations in his use of alcohol and perhaps sleeplessness might be due to some approaches around grief and the grief that he might be experiencing about his perceptions of himself, his role, his relationships. Acknowledging too that grief is not just about death and die and grief is very much about a neurological, a biological, a psychological reaction to any significant change where we have a perception of one of lots, which is either primary, which is a loss of interest, secondary, which are things related to it, or tertiary, more broader issues that we can expect to person. We also need to understand schemas and how they've informed Warren to find solutions and inform his values around his life. And understanding that schemas is a mental structure that people have to organise their world around them, how they make sense of, you know, one of his business perspectives, how successful he expected to be in his life, you know, how he expected to be able to manage things and be able to hold his face up in the community successful in various parts, so that we should perhaps have had an expectation that he should cope with stress. What I've got up here is just a diagram of the Schema Activation Formulation, which when I had a face-to-face with Warren or if this is something that could be emailed to him, so that you could sit down with him, actually work through various aspects of the other thoughts or emotions, behaviours, and how some of his schemas or his core beliefs and feelings that he might have about himself and what might be some significant triggering events. This other diagram that I've included here is to actually look at the dual processing model of grief, which is really useful when we're looking at grief from a non-death or even from a death perspective, but working with Warren to actually look at what might be significant triggers that are taking him from focusing on his losses as he perceives them to actually looking at how he's adapting and how he's actually focusing on life's changes and how he can make sense of what's going on in his world and actually find what could be triggers now but also preparing him in the future for other triggers. And I think this one I've had to perhaps offer here to this is just perhaps a therapeutic approach to add on to what Lauren and Jacinta and David have also added to this scenario for Warren and his family. So thank you Conrad and others, so that's my perspective. Wonderful, Julianne. And well actually that brings us to the Q&A part of the evening and actually I'm going to return to you Julianne before we leave you again. We've already mentioned that as this initiative requires both telehealth and face-to-face deliveries and as you've said it's great to be able to get that first face-to-face consultation with the client to really get that engagement in place. How would you decide then on which aspects of the therapy you'd allocate to each of those modalities face-to-face or telehealth? Conrad, that's a really good question because I think sometimes that's about that art of the clinical skill in trying to assess perhaps where Warren might be. But I think from a general rule of thumb it might be that a lot of the more educative and practical aspects of therapy can be really quite easily delivered on telehealth and some of the more deeply personal or where you really want to engage with some... You know, where you need that eye contact or face-to-face with the person to unpack just what some of their reactions or some of the problems or new issues that might have come up over the time between each session might be more easily done in a face-to-face. And I'd actually suggest that to Warren early and say there'll be times when things might be tricky or difficulty might feel a little bit that he's not coping with other things or new things have happened and we need to re-ing... And I'll have something set in cement but know that we can actually re-engage with the face-to-face if that really feels more beneficial at the time but that we'd actually try and structure that more educative stuff was done over the telehealth and the more engaging face-to-face stuff around personal, you know, issues that you might want to unpack. Great. Great. Just since we might move on to you with the next question there, as you mentioned in your presentation that sort of having a plan in place about risk and what might happen with being able to go through that discussion with your client early and that the picture really is so important. What might be some of the simple strategies you might suggest to our participants to help de-escalate the stress of an agitated or at-risk patient during a telehealth consultation? Yeah, thanks Conrad. That's a really important question. In the absence of the first thing we tend to do when we're face-to-face with people and they're struggling is to offer tissues, a glass of water and it's not something we can do in a telehealth consult. So quite often I'll coach people in gathering those items, doing a little bit of self-care themselves. Have you got a tissue close by? Would you like to get yourself a drink of water? And then the next stage might be to guide them through a simple breathing strategy or grounding technique such as getting them to describe all the objects around the room just to get calm. If that's not working we might enlist a family member or somebody close by to provide some support if they're present. And we might develop a plan of action for what they're going to do following the video conference for themselves. If it develops into a serious emergency we would stay on the conference. I would look to be calling an emergency service. And some of the little things that will be important to think about is if the client's at home by themselves, Warren's at home by himself, he's getting him to unlock the front door to allow access. And other sorts of things we've done before is getting people to throw self-harm implements in the garden so that they're out of reach, that type of thing. So that's getting quite extreme, but those are the sorts of things that are good to have in your back pocket when you need them. Thanks, Conrad. Thanks, Athena. Amongst our participants tonight are a few questions. You raised the point about this might be a better way to help with the maldistribution of typologist services across Australia. I guess it's easy for all of us to think about we're talking about rural psychologists and certainly our panellists tonight have predominantly been from rural areas. But as you see just in there that we may actually also have health professionals working with social and emotional well-being for patients who, although they might be based in metropolitan areas, certainly are capable and able to provide outreach services. And we have had the mention already of what happens with fly and play out workers who might be based in the cities, but when they're actually away on shift or out on their roster. Although they might be actually geographically very distant from their usual mental health professional that this might be a way of being able to provide continuity of services. Unfortunately, we're not able to address all the questions at private billing arrangements. Those are certainly something which you'd need to discuss together with your clients as your own circumstances evolve. But we're certainly talking about the Medicare funded rebates that are available under the mental health treatment plan. We might actually then just return to you, Belinda. Some of the other patients have been asking about eligibility for other groups of patients. We've got talking about children or client under 18, but also eligibility for group sessions as well. What sort of flexibility around these arrangements are there for professionals, Belinda? No, that's a great question. So the new telehealth items have been structured around the existing better access items. So there's no age limit in terms of services to children. It's really just whether or not it's clinically appropriate for the practitioner to determine that it's clinically appropriate to do that service with a child over video conferencing. And these items are definitely available for group sessions. And again, the practitioner needs to think about how best to run that with the group and think through the clinical and the technical issues, but there's no restriction on group sessions under the telehealth items. Sure. Thanks for that. It's really great to see some of the points coming through about the importance of being able to use still those non-verbal techniques. Jacinta and Julianne, we're both mentioning about all of those other practicalities, even if you're based on an internet connection, still being able to pick up on eye contact and voice and everything. And you know, as professionals, we'll all be aware that it is particularly important when you're not in the room to make sure that you've got that at that in place. Some other participants have also been talking about the applicability of this for people who might not engage well with face-to-face consultations, particularly for patients who suffer from severe anxiety. That's a great point. But we'd have to remember that for those consultations, they're still down by that same guideline of being 15 kilometres away from the treating therapist for eligibility. But it's great to already see a little bit of creativity and imagination coming into the way that participants are thinking that they might be able to apply this into their own settings. It's also interesting to see some of the comments regarding what happens with Apple versus Mac or Apple versus PC. Yeah, I don't know what all of the options are for Apple if it's based on not HP AAA compliance, but you can certainly still be being able to download the apps when appropriate. So we might take this opportunity to sort of recap a little bit on what sort of ways that we each think that we might be able to sum up the key points for each of our participants into Warren's care. David, what do you think might change for you in the way that you'd be better able in the future to look after somebody offline? Yeah, thanks, Conrad. Look, I think the key thing about this is it just provides an extra string in my bow of things I can do for all my patients. And it's about finding the right modality for each patient and to allow access for rural patients to see a psychologist and to help bridge that gap, so to speak, that exists and the lack of access is something that I think is really important. So I think for Warren this will give me a chance to open up to all sorts of other practitioners. In my local town, we occasionally have a psychologist visit, but now I can explore other options amongst other allied health practitioners just about anywhere in Australia. So I think to be able to tap into that resource, especially with regards to people with particular interests, I can now try and find a practitioner who's got a particular interest in what my patient has, and I think that's fantastic. Very, very good point there, David. We don't have to be constrained by that traditional geographical distribution of the best professional for the job. If we've been to a workshop and we've met somebody fantastic in a metropolitan area, even though we ourselves might be in a rural practice, if the patient is willing to still go and have a few face-to-face consultations with them, this really is going to provide a great way to provide ongoing care put for those patients. Just answer. You know, you're based in a metropolitan area. How are you finding that this type of initiatives might be changing the way that you can deliver care? Sure, yeah. Look, we already do provide a fair bit of telehealth. Obviously, it's not under Medicare, but West Australia is a huge state. And there are a lot of people living in those rural and remote areas. We find that a lot of the time they need to travel to Perth for consults with specialists, pain specialists or psychiatrists or whoever it is that they might be needing to see. And that is where the referrals often come from for us to see people. And they then... We've then talked to them about their options, and quite often people will choose, even without a Medicare rebate, to have a telehealth consult simply because it makes it much easier for them to access the service. But with the Medicare rebates available, this will just make it so much more affordable for people in rural areas to access quality health services. That's when I think that's a wrap. Yeah, absolutely. Phillips raised an interesting point there, that when it takes a few sessions, obviously, it's to be able to really build up a therapeutic rapport with a patient. And we might find that it's taking first three sessions, really, to notice that there's something there. We would certainly still be hoping that just as we do current reviews for mental health treatment plans, that we'd be able to send an update referral back to the... back to the referring GP to say, look, you know, we'd want to be able to access further access for these patients. Linda, we've mentioned already that the requirements for patients to be receiving face-to-face and telehealth consultations under these initiatives. But the comment has come up on a few questions about what happens when the travel is prohibitive. Do we have any flexibility with that, or is it really up to the GP and the patient and the mental health professional to decide about where that distribution of services is going to be? Yeah, so there isn't this flexibility to extend telehealth to all 10 better access services. The rules around one of the first four sessions being face-to-face, we're not able to offer exemptions to that rule. So it is up to the practitioner and the patient to sort of think about how they might access those face-to-face services. Great. Okay. Thanks, Linda. Now, I noticed that although we've got some participants logging in from overseas tonight, I don't think we can actually apply the utilisation of these IV numbers to overseas professionals. We are only talking about the mental health providers registered with AFRA and eligible for Medicare rebates in Australia. So now we can't start referring people to Germany or to Texas even though some of their participants might be overseas. Lauren, we've mentioned already about some of the modalities which would be appropriate for these patients and you've certainly known the ones which work best for you. How might you find that you are better able to utilise these initiatives in your practice? Well, the distances aren't as great here as they are in Western Australia. So it has people actually coming to the office mind you, 400 kilometres for that one lady recently was a long way. But generally, it would be about similar to Warren so it would be about 50 kilometres or 100 maybe. So I think, yes, that would enable a two-year combination and sometimes it's with clients you have already seen for some time as well. I'm thinking of people I've seen in the past and seen through private health cover and I've seen them for quite a period of time. Face to face. And then one chap has got a job that takes him over half the state so he's often in his car driving around. And from that point of view, the telehealth initiatives would be very good for him in that we could access each other no matter where he was really. So I think that would be a great benefit. So, yes, the combination of face to face and telehealth would work well for me. With some of the other results from the studies it indicates that social anxiety, previous social anxiety really appreciate being able to use the telehealth health initiative or process. So I guess we need to be mindful that sort of keying into their importance of situations but also we still need them to have their exposure sessions and so forth just because they're not coming into the office which would make them extremely stressed. We do need to set the homework for them to do as well. The other thing that was mentioned in the studies was it reduces the no-show that people don't come sometimes because they haven't got the petrol or their car breaks down or haven't been paid or whatever so they can't afford to travel in their car and so they will still accept a conference call. So I think that that was quite interesting as an outcome. One of our participants, Josh, was a bit concerned that we're overlooking the difficulties that some of our patients have in accessing face-to-face consultations. Josh, I guess that means you're hoping that we'd be able to deliver all of these consultations through telehealth. I think we've actually covered quite well there that the importance of using that initial consultation if available to actually build up that personal therapeutic relationship really get a proper assessment of the client there in front of you and hopefully be able to build on the progress of that first session with some subsequent telehealth visits. Yes, we acknowledge that certainly there are still barriers that occur. This is a big country and it is difficult for clients but we'd hope that sometimes that the face-to-face might be two ways as well that there might be occasions where if you actually do start to notice that you're developing a number of rural or remote or regional clients that it might occasionally be worthwhile you coming out of those areas and maybe being able to access the group visits or being able to schedule a few face-to-face attendances for one visit out to the rural area and really be able to actually see that the environments that your clients are living in. But we most certainly do acknowledge that it can be difficult for our clients to come into metropolitan areas and that's why David certainly pointed out in the early stages that it really is important to find out what are the travel subsidy schemes which are available in your state because all of the different state health departments do have general guidelines regarding the provision of those services. And Julianne, we might just move finally back to you then on how you see that these initiatives might help you with opening up an area of practice in your work. I think it's been really well covered with Lauren and Cinta and David as well talking about how wonderful it is to actually add it as a suite of options we can to our clients. And I think looking at that tyranny of distance is really good. I also think to enabling or enforcing that we're still going to have some face-to-face means that we still have to try and find fairly local people. People within the one to 200 kilometres we're not always going to go to someone like where I am in the Riverina and thinking that well, I'm not going to use anybody locally. I'm going to go completely outside the area. I think those safeguards about having maybe the face-to-face sessions are a safeguard to still think local and not think you've always got to go for rural people to metropolitan areas. I think from my practice as a social worker here that we offer a specialised type of service and grief and trauma that enables clinicians to choose perhaps people who've got a specialisation. All like David's point, it's actually tailoring or finding the right clinician for the right client because sometimes you don't have the right service in your area so I'm quite excited about the initiative with Conrad and I welcome the department's initiative on this. And certainly as we're going we've got a lot of participants obviously online with us tonight who have all got special areas of interest and I guess as a GP working in rural area myself and David will be in the same regard that we don't always know that so it's so important that when directories such as that provided by APS are coming out that they really do give us as the isolated clinicians an idea of what those interests are so that if we do have somebody who we're wanting to talk about grief or trauma-related illness that we really know who is the best one to be going with that and certainly making sure that when you do update your details that you do have your contact after date obviously we're seeing that what is your preferred platform and what might be the requirements that you have for usernames and for downloads and all those types of areas as well so I certainly share the enthusiasm of our panel so I know certainly that in this area we struggle with access to mental health professionals and to know that we've got that diversity of services available because it's one thing for a patient to be able to get down to one or two visits in a major area but when you're talking about five or six it can really become quite difficult so I know that this will certainly be the way that we move into the future and to some of the other panelists sorry that the participants yes this is 1st of November is when this initiative rolls out is that correct Linda? Yes it is so two weeks and a day away I think well bring it on, bring it on that's great alright so well as we wrap up then we certainly thank all of our all of our panelists and our participants for their participation tonight you'll see the resources links down at the bottom of the screen there and not only is that fantastic tonight but there'll be a lot there to the Department of Health guidelines and also those frequently asked questions which you've been coming up with and breast assured that even if we haven't been able to cover your particular comments tonight the Department of Health will be holding on to those so that they can actually make sure that as they do their revisions of this initiative and work on refining it for the future that we can make sure that it is personate and remains contemporary because obviously there's only so much that the focus groups can provide when you actually get real clinician experience as they've had tonight it's invaluable for them to have all these perspectives so thank you everybody else for your concise and respectful comments as we've gone so we're now going to wrap up on this one. I hope that you've enjoyed the session and that you've got something out of it. We invite everybody to register for the upcoming MHPN webinars that's going to be on internet gaming addiction and the effects of mental health that's coming up in a few weeks on Wednesday 22nd of November. We also ask everybody to please make sure that you complete the feedback survey which is going to be clicking up for you. It really is through the use of those feedbacks that we really are able to guide with which way these sessions go and make sure that they're the most valuable for you. And if that doesn't actually come up you can certainly just click on the tab at the bottom of the screen. If we've got your current email address you're receiving your typical attendance for tonight's session but within the next four weeks and you'll also at that stage receive the link to any of the resources mentioned in the resource library there tonight. So we hope that you've enjoyed your experience with the Mental Health Professionals Network. We encourage you all to increase your involvement and please consider signing up as a facilitator in your local area as well. But no, with that I think that we'll be happy to acknowledge that we always make sure that we are always mindful of the support and engagement of those local networks that we've got. We know that being able to have these inputs from different modalities of treatment really do make such a difference for our mental health patients. And we would like to see all of you consider whether you might be able to increase your participation in these networks as we go. So we are just going to finish with acknowledging the consumer from the carers who live with mental illness in the past and those who are continuing to live with mental illness in the present. On behalf of the panelists and the Mental Health Professionals Network thank you very much everybody for your participation, Seeding and Canoe.