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"Wait List Risks"

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Megan Walker: Hello and welcome to Market Savvy conversations. My name is Megan Walker your host, and today our very special guest is Kaye Frankcom, who is a clinical psychologist and we're going to be talking about managing your waiting list and the bigger picture issues that might be causing some waiting lists challenges. Kaye is a clinical psychologist as I've mentioned, and this will focus on waiting lists, particularly relevant for practices who have got patients with mental health risks. Hi, Kaye. How are you?

Kaye Frankcom: I'm very well Megan and great to be with you today to talk about this very gnarly issue of wait lists and to talk a bit more about the context of that.

Megan Walker: Thank you so much, Kaye. For those people listening who haven't met you yet, can you just give us a couple of minutes background so they'll hear what good hands they're in very soon. Let's hear your studies, where you've practiced, about the business that you ran and what you do now?

Kaye Frankcom: I started off working in regional Victoria in a small town of about 10 000 people and then I went into then having practiced in a private practice in regional Victoria and I actually started practicing before there was Medicare, God help me. And then came to Melbourne, 20 years in suburban Melbourne, running a practice that ended up being 16 psychologists. I sold that back in 2019. Since then I've been coaching and supervising other psychologists in their practice, both solo practitioners and group practice directors. In addition to that, I've been on the Psychology Board of Australia, I was the President Psychologist Board of Victoria, which is its predecessor. I've done a lot in the area of practice standards and that sort of thing, and wrote a book called Fit to Practice some four or five years ago now. You'd be glad to know there's another one in the works.

Megan Walker: Watch this space.

Kaye Frankcom: Watch this space.

Megan Walker: As I mentioned, in good hands. Thanks, Kaye. We're going to start off by talking about a practices caseload. Kick us off, who's in the case load? Go for it.

Kaye Frankcom: One of the interesting questions I find when you're talking to psychologists is you say to them, "How many people are active in your caseload?" They go, "I don't know," and this is a bit of a concern because you can't really manage a wait list unless you know how many active cases you're treating and how many sessions per week you can offer to your existing caseload. First of all, let's help the people that are already working with us and make sure that we're maximizing what we're doing in terms of being able to offer them appointments when they need them and to move them through a treatment plan. Because essentially with the kind of pressure that we have at the moment, we've got 20 to 30% uptick of referrals from GPs into most practices. Particularly in our three big states Queensland, New South Wales and Victoria, despite lockdowns and COVID and the whole hoo-ha if anything, that's really what spiked this, that we really need to be clear with that with ourselves and with our clients as to how many sessions we may have require to give them for that treatment plan.

Once we've got into it, once we've assessed them, once we've got a fair idea of what we're going to work on and we set some goals, is to be able to talk with them about that. Of course, now we have 20 sessions that is allowed, that can stretch out and really make for a wait list problem, because most of us have been used to working in 10 session blocks. I think it's important to know what is your current caseload. If you aren't a full-time, if you're working a four to five day a week, you shouldn't have more than 35 to 40 clients on your active caseload. If you're more two or three days a week, it's obviously going to be around half that. It's thinking about, okay, what is my optimal caseload? How many clients can I see? Some people can see seven a day. Some people can see four. The average is probably five to six.

And of course, then you look at how many weeks there are in the year and you take away the amount of leave you might like to take and please be taking leave even if you can't go anywhere. Just take some time out at the moment in this pandemic, which is dragging on and will drag on for some time to come. I think it's just thinking about this current caseload and optimal caseload, and then looking into the caseload. Who were people that you were seeing because they just keep showing up. Now some psychologists believe that if the client keeps showing up, then who are we to say go away or discharge them. To me, it's a conversation you need to have. Some people do need long-term care, but some people don't.

We often don't talk with our clients at the early stages about how would we know when we are done? When you got whatever you need from here? Because there are risks for people staying in therapy for longer than they need. They can deteriorate in our care because of course, psychologists can always find a problem to work, can't they? We're very guilty of that. But also there's dependency on the counseling and dependency on the clinician. We want to try and minimize that if we can. All of these things are really important to think about because almost all of the literature we have on outcome out of therapy says that most of the outcomes appear to occur or the most change appears to occur in the first seven sessions of any therapy of any kind.

We want to maximise that. And then once we get passed that, I guess the question is, what exactly are you...? Can you continue to work in episodes of care with this person? That's fine. Particular things you've decided to work on over time. But supportive counseling in this environment, it's a question mark for us. And I think sometimes we have people we're seeing in this maintenance fashion where perhaps a third party is paying for the service, like you will work covers and so forth. Or the person says you're the only one who understands me, I wanted to keep coming. That we then fall into seeing that person in and it's in some ways, this is a bit of a dirty little secret Megan, and you're not to tell anybody, but I think for me [inaudible 00:06:41], it can be a cruisy session. And when we're under stress ourselves feeling a bit burnt out, don't have access to the usual supports we'd be happy to have so we can support our clients, then some of the supportive counseling sessions can be a bit of a break from the complexities of other people that we're actively treating.

Megan Walker: Yep. Makes sense, doesn't it? What about returning clients? What's your suggestion there?

Kaye Frankcom: I think you have to have a policy in your mind about, if somebody is being discharged for six months or more from your client load and then returns to treatment, would you consider treating them as if they were a new client and saying to them, you have to go back on the wait list? Some clinicians might say, well, some people I've said to them, "Come back when you're ready, we want to do some more depth work together", and they might show up and you might say... I'd say, treat them differently. Treat them as a segment of your clinical load. But I think if you just give people that opportunity to flow in and out without you actually controlling what's going on and having a policy that you can enunciate to them and explain to them why, then the wait list will run your practice, not you run the wait list.

Megan Walker: Interesting. I know we're going to talk about different ideas for addressing the long wait list, but is one option to take a more niche focus with your practice?

Kaye Frankcom: Do you mean niche presentation?

Megan Walker: Yeah. What's your thoughts there being more specialized? I know we're not allowed to use that word, but having a more focused-

Kaye Frankcom: Sure. I think when you're working in areas like an eating disorders or a personality difficulties or chronic pain or whatever it may be, ASD presentations and associated mental health problems, you definitely can have a niche market. And you may, in that respect, be able to be more clear about how long you're going to work with the person on whatever it is. The difficulty where something like the NDIS for example comes into play is, once somebody starts with you under the NDIS, it can be an endless piece of string as to how long you work with that person. Because there's an assumption that they may need long-term care and that could be a true assumption, an objectively right assumption. But I guess the question for you as a clinician is how does that fit with what your passion is and whether or not you need to see some new clients every so often in order to keep yourself renewed and feel vigorous in the work you do.

For some people, people are happy to see somebody long-term and that's that long-term psychotherapy work is what they do or long-term support or somebody with a disability and working in a multidisciplinary team or longer term work with eating disorders. I'm fine with that, but just know what it means for you as a clinician, because it will mean you are shutting the door potentially. You could be shutting the daughter to an active wait list because you just say, look, my books are closed and that's that. But you also have to ask yourself, do I want to make space for new clients? Is that my responsibility or my response to the pandemic? Nobody's responsible to the pandemic, but do we want to be responsive to the environment we're working in with this uptick of referrals? Or do we just keep going on our little way and not deviate from that and hope that the nasty world that we're currently moving goes away sometime soon? It may not be an effective to respond to them.

Megan Walker: Would you suggest setting aside new client appointment spots?

Kaye Frankcom: Again, it's up to you. But yes, I would. I would say that having the opportunity to take on new clients, it allows referrals to recognize that you are capable of doing that. I think saying to a referrers, I've got a wait list, you need to really be clear about what that means. To my way of thinking it's about thinking about what sort of people you don't want to have on that wait list in terms of presentations and risks. But I think if you have new client opportunities, then you can also say to a GP that you like to work with, I have got two new client spots per month and they are available first come first serve. If you have somebody who would fit that criteria, who will be a new client and perhaps somebody who only needs a small amount of sessions, because most of their difficulties are in response to the pandemic.

Because remember the uptick, we think this is the analysis we've seen from the Australian Institute of Health and Welfare's statistics out of Medicare, we think that a lot of the uptick is to do with people who have never consulted a mental health clinician before. We think that some of this uptick is coming out of the pandemic. You might say to your GP referrers and so forth, "Hey guys, I've got a couple of spots for people with pandemic responses and mental health related responses who might just need somebody to intervene now, give them some coping skills, work with them on that. And then out the door in maybe six to 10 sessions." 

Megan Walker: My marketing brain likes that for the, keep in touch factor. We're still here, we're still in practice. We haven't gone to ground and we're not communicating with everyone because we're so overwhelmed. Keep those lines of communication open.

Kaye Frankcom: Yes. I think the other thing about it is to recognize that GPs want to hear that we're responding in a nimble and agile way. We might say we've got a set of resources that we send out to people who do go on the waiting list. If you have somebody who you want to refer, then we will send them an expression of interest, whether they want to activate that referral. We can look at ways in which we have stagings in our wait list process, which I can get into as we talk some more. But I think part of it is about saying, are you aware of these things? We're also are aware that so-and-so practice is running some groups to support people, or there's the Head to Help hubs, which, go have a look. There's a number of them. Certainly Victoria, they're being trialed also in New South Wales these days, I believe.

These are basically triaging services with mental health clinicians available on phones, on video, or in some cases in person, who will support people until they can get an ongoing therapist. I think it's really about being aware of our fellow health professionals. GPs can't say go away. I don't want to see you. They don't do that. We are of a different nature. I understand that. But we also have to realise we're a team. This is team health, team mental health, and we really need to be responsive to our GPs and talking to them about what can they see that we could do better? That then we could respond to this overwhelming needs, given our limitations, rather than just putting up the hand and going...

Megan Walker: Shut. Kaye, getting into waiting lists a little bit more, talk about what limits should be put on wait lists, how long should they be, false figures, restricted per clinician, et cetera, get into that detail a bit more?

Kaye Frankcom: One of the things that really concerns me is people... I certainly speak to practitioners who are in group practices where somebody is putting a client on a wait list for a... Sorry, is putting somebody into their diary to have their first session in November. There might be a number of those people. To me, that's sort of a pseudo white list. And the difficulties in managing your diary is you might get to November and that person's gone off somewhere else. They don't want that appointment. To me it's a bit of a pseudo wait list really and it isn't really appropriate. I think if we can't offer a session to somebody within six weeks, we have to ask ourselves whether we're ever going to be able to offer them a session? That's one parameter. People are welcome to expand that and have a different timeframe.

But I think having a timeframe that you at least can, again, have as a policy and enunciate to a potential client. You can say, I'll take an expression of interest that you had in joining our wait list and coming to see one of our practitioners but until I have a GP referral or your care plan, I know your availability, your demographics, or your next of kin, your referral reasons, I can't really actually allocate you. I can't allocate you either as a general wait list person or to a particular clinician given your presentation. I think it is about for your whole practice, do you wait list each individual clinician, do you start off with what I'm calling this expression of interest level before you then... Once you got all their paperwork, they then actually join the wait list. And then when they do join the wait list what are you going to do about monitoring their risk?

Megan Walker: Absolutely. How do we know that they're not?

Kaye Frankcom: Asking somebody, could you tell me if you're suicidal or not, my dear? It's probably not a role we want to give to a reception person necessarily. It could be an okay thing for an administrator to do, but they will need training and support because what if the person says yes, actually I've got the means to do it right here next to me. If you don't give me an appointment today, I'm going to take my life. That can happen.

Megan Walker: Just a sidebar, sorry, Kaye. Can we just address that? I know it's a massive thing. But what does someone do in that situation just so we don't leave that one hanging?

Kaye Frankcom: Well, I think that the fact of the matter is an administrator then... Hopefully before they've actually had that conversation, they have next of kin and some of that demographic material, but it may happen that the person just rings up on spec. To my way of thinking, it's keeping them on the phone and having a chat while you're sending an email to your practice director or another psychologist who might be in the practice, a clinician who's in the practice and asking for their support because you may or may not be able to do anything.

If you don't have enough information to then send a police officer around for a welfare check, which is what we would do here in Victoria and other states, it's a similar process called something else, but essentially a welfare check. You have to have an address. You have to have a name, you have to have a phone number. As soon as somebody's ringing in that you're mainly writing down, hopefully the phone number that's come up on your PABX or whatever that tells you their number. But you don't necessarily know a next of kin or any of those things to... Because the activation process would be to first of all, see if you can get them to talk to you and find out who's around and who knows of their circumstances and what supports they have and to get a next of kin who you could ask to intervene before you involve police.

Megan Walker: Thank you for answering that. I thought I'd better just go down that path a little bit more. It's such a critical one. We might have people on four different wait lists in their 10, 15k radius or further, depending on where they're based.

Kaye Frankcom: That's right.

Megan Walker: Waiting for who's available next.

Kaye Frankcom: That's right. Most practices are saying to people, don't cease looking, just because we're putting you on our wait list, looking for other options. There are other practices you may want to be, as you say, on multiple wait lists, which is why you've got to manage it and why you need to make it a fairly specific period of time that you try and offer an appointment to this person. Sometimes people say, "Oh, I don't care. I'll just wait however long it takes." Well, maybe they will, but it's not necessarily in their best interests. And I think sometimes we've got to think about the fact that the people who are approaching us for services and not necessarily the greatest judges of what's in their best interest. That's part of the reason that they are coming to us is because they don't know how to help themselves at this point, either because that's a new experience for them due to the pandemic or that had ongoing mental health conditions and issues over time that have led to that.

Megan Walker: Yeah, really good point. Absolutely. And then people going on our wait lists, some other things that you've talked to me about is when they have complex considerations, what do we do there?

Kaye Frankcom: I think we need to be asking if we are going to go to this triage routine with our wait list, we need to be thinking about family violence. Now, asking directly somebody, is there a family violence in your household, may or may not get you anywhere. But asking whether they have any apprehended violence orders that are involved in their situation and or family law matters that are afoot, could help you to suss that out and potentially might lead to that person having a conversation with your practice director or somebody more senior, not with the administrator. I think sexual abuse, current sexual abuse, that could require mandatory reporting. Again, this is a different level of referral that I think you need to think very carefully about putting somebody with that kind of story on a wait list and where there's trauma complexity. 

I guess I'd say, where there are other considerations as well. Again, is the trauma historical or current? What is the age of the person who was enduring this trauma? What other supports are around them? Do they have other clinicians, health services involved? Again, family law, apprehended violence orders, child safety, department of human services. This is if you're dealing with adolescents and young people, obviously. Headspace. You might need to be asking questions about who else is in the picture before you weigh in to be in the picture yourself.

Megan Walker: Medical and clinical receptionists, the good ones are just worth their weight in gold.

Kaye Frankcom: They are gold.

Megan Walker: And the training that's required these days is next level, isn't it?

Kaye Frankcom: They need maturity often, but you can follow maturity on the shoulders of students and provisional psychs who often also perform these roles because they're in the process of training to be that clinician who will have to deal with that kind of presentation down the track. But it's really important that they are very strongly supported and managing wait lists. There are certain people that you and I know in this consultant coaching space, who just say, don't worry. And you can see why, you can see why. It's really tough.

Megan Walker: The black and white approach.

Kaye Frankcom: Yeah. Just service the clients you have and worry about a wait list some other time. The difficulty is, I think, it just is impossible at the moment to be referring people out running, as I call it, the citizens advice bureau, which most people who are under 35, don't even know you're talking about. Citizens advice bureaus of course are places referral. In the past you would say, oh, look, so-and-so, we know they've got spots. Yu can probably make contact with them. There is no one at the moment. I've never in 35 years of practice had so many ring me saying I've got depression and anxiety, pretty straightforward. I need some sessions around workplace issues, family stuff, whatever. When you say to them, I'm very sorry, but I actually do not know anybody who could take you in the foreseeable future.

Megan Walker: Unbelievable.

Kaye Frankcom: I pride myself on having a raft of people who either work for me, or I've worked with who I can say, oh, so-and-so would be perfect. And they're in your region. This is just not on the cards at the moment. We end up suggesting things like Head to Help hubs and places like that where there's triage, but also where they are certainly more aware of what's available and what's not available.

Megan Walker: Kaye, I'm going to ask you about some lighter touch options that as you just started alluding to there, where people can start to get a little bit of support while they are on the waiting list. We've got a bunch of other questions that I want to go into about that whole triaging and more around the training and support internally. But let's hold that over to a part two, if that's okay.

Kaye Frankcom: Sure.

Megan Walker: We can give people some food for thought on this topic, have some pause and reflection and then have a second session. Of course, I'm a fan of creating even your own little mini online course that can have some useful videos and resources for people. Tell me about some interim things that clinics could be giving to people for that six weeks that they are waiting for an appointment.

Kaye Frankcom: One of the things I would say to you that is not that hard to do is to actually get your website person to develop a learning management system for you.

Megan Walker: Or Kajabi.

Kaye Frankcom: Or just use one of the platforms and see if you can plug it into your website and then just go on there and start talking about... Thank you, welcome to our practice. You're watching this because you've approached us for services. And at the moment, we may not be able to provide those services straight away. We are going to go through a number of options that are available to you that have possibly been told to you over the phone, but here they are in writing, in a visual presentation. And then you can go into, there's the happiness track course, there's There's The Way Back Support Services, there's suicide prevention services, there's your GP and so on.

And you can have potentially a slide set on each of these, that it has a slide on each of these services that people can then watch a few times. Just talking about mental health, first aid, looking around for groups that they could join online that would help them and support them, there are those. And I think, thinking about things like telehealth services that are available, if your tele health is full as well and you're maybe not even offering face to face is, have you got a relationship with a national telehealth mental health provider that you would feel comfortable to send people to and do they have a waiting list?

Megan Walker: And it's an interim measure, we appreciate it. It's not going to give the full depth of a one-to-one clinical experience, but at least there's something to go on with, isn't there, while we do have this...

Kaye Frankcom: Exactly.

Megan Walker: Deficit of availability. Kaye, is there anything else in keeping in touch with people on the wait list, should we wrap up with that one? Checking in, making sure they're okay. What's a sensible timeframe for doing that, do you think?

Kaye Frankcom: I think if you're hoping to offer somebody a session within a six week period be in contact with them weekly. And obviously if you've triaged them through automated processes, so often people are sending out a lot of automated materials that have to come back, you need to convey to them, unless we have all your materials, you will not go on the wait list. That's the first thing. Second thing is that somebody will call you, text you or email you, which is your preference?

Megan Walker: Yes.

Kaye Frankcom: We then have to decide what are we... Because you're going to have to put aside some admin support time to do this stuff. This is why if you're a sole provider, which we have 50% of our registered psychologists are in that environment, you need to think really carefully about having wait lists of any kind, because you could spend half your life on the phone to people.

Kaye Frankcom: I've certainly spoken to the psychologist and said, you need to stop taking phone calls. You need to automate what your responses to inquiries. You need to leave messages on various phones that you've used and say, I'm not really responding to phone calls. You need to email me, or check out my website, which has all those stuff on what you need to do if you want to go on a wait list. Just really making it so that your time is not taken up, that the clinician's time is not taken up with any more of the management than they need to. But once somebody is actively on a wait list, then there is a duty of care to just keep in touch. And people say to me, but they're not actually our clients as yet. I go, well, you can explain that to the coroner when that person decides to do something to themselves, while they were on your wait list and somebody discovers that's where they were waiting for a service and you hadn't talked to them for some weeks.

I'm not a great one for too much catastrophizing and people saying things like, I never write anything in my case notes, because then I won't get into trouble. Really? Or I leave people on a wait list and don't contact them because then I don't know what their problems are so then I'm not responsible. These are not ways to manage things. We are professionals. We need to be able to explain what we're doing in a clear and understandable way. If the person is outside of our scope and outside of our policy, we need to explain to them why. And we need to manage ourselves in relationship to that wait list by keeping in touch with people and asking for their feedback about whether they still wish to remain on the wait list, because they may have found somebody else to see or some other way of handling their difficulties.

Megan Walker: Here's hoping.

Kaye Frankcom: Here's hoping.

Megan Walker: Kaye, thank you so much. I love talking to you because you're so super practical. You're an incredibly intelligent person who can bring it down to this is how a phone gets answered. I just love that you have that ability to get into the minutiae of what is needed to help people. We're going to have a second conversation if you're okay to do that, because I do want to touch on our golden receptionists and what more can be done around them. How do we brief therapy models? We've got other things that we can talk about, but if people are interested in supervision or business coaching with you, which is your mainstay, how do they reach you?

Kaye Frankcom: Well, there's a wait list. No, there isn't.

Megan Walker: You're a meanie.

Kaye Frankcom: Sorry. Black jokes. Sorry about that. Black humor. There is not a list. People are very welcome to make contact with me, [email protected]. Check out my website. I'm available to do business coaching and supervision. Often, it's a combination for many people who are in small practices, solo practices, and it's a a boutique arrangement from my point of view, Megan. And I'm there to help you achieve your business goals and obviously to offer the best experience you can to your clients and have a satisfying life in these difficult times in terms of your workload and the passions that you have for your practice. That's me. There's no upsell. There's no lock-in contracts. It's just an hourly rate and we work out a business plan and we go from there.

Megan Walker: Beautiful and everyone needs that support. We all need a Laurie Lawrence poolside at the moment, cheering us on.

Kaye Frankcom: We sure do. I think that's a great analogy that everybody needs a cheerleader, but they also need somebody who is able to interrogate what's going on and help them to fix some of these issues that they may be facing.

Megan Walker: Fantastic. Kaye, thank you so much. Love the conversation. Looking forward to part two. I'll talk to you soon.

Kaye Frankcom: We'll do it. Cheers, bye now.

Megan Walker: Thank you. 



Visit Kaye's website: Kaye Frankcom | Clinical Psychologist & Coach

Email: [email protected] 

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