This case study focuses on an Indigenous patient. It gives examples of suitable General Practitioner Mental Health Treatment Plan (GPMHTP) item numbers.
Case study
You’re a GP with mental health skills training, practising at a remote community health service. You have an 18-year-old Indigenous patient who has:
- a history of good physical health
- only required minimum medical attention in the past
- recently had a health assessment.
Assessment
The patient visits you about an ongoing sleep issue that includes several bouts of insomnia. During your discussion, your patient becomes teary and shows signs of mood swings. You assess that they’re not experiencing any other physical health issues requiring treatment for their sleep condition. You’re concerned about their mental wellbeing.
To address your patient’s mental health issues, you determine they would benefit from a GPMHTP, item 2715 or 2717. You discuss this plan and they agree. You record their acceptance to proceed.
You collect information about your patient’s past and current conditions and perform a mental health examination. During your discussion, your patient reveals that for the last 6 months they’ve:
- experienced feelings of isolation and low self esteem
- avoided social contact from friends and family
- had periods of sadness.
You assess that your patient is displaying signs and symptoms of depression and may need psychiatric evaluation.
Preparation of the GPMHTP
As part of your strategy to improve your patient’s mental wellbeing you:
- determine that you should refer them for individual allied mental health services with a psychologist
- discuss your assessment and strategy for managing their mental wellbeing, including the benefit limits for mental health services provided under Medicare - they agree with your plan
- complete the necessary referral and arrange an appointment for your patient with the psychologist
- document all required information in their GPMHTP and provide them with a copy.
Review and ongoing support
As part of your strategy to improve your patient’s mental health you:
- schedule an appointment for a GPMHTP review consultation in 4 weeks’ time using item 2712
- assign follow-up services with the Aboriginal and Torres Strait Islander health practitioner to monitor risk of self-harm - they’ll review the patient during weekly visits to your patient’s community
- consider the need to refer your patient for a psychiatric assessment
- continue to provide ongoing care and management of their mental health disorder.