Regional planning and the Implementation of Integrated Mental Health Care: the experience of Partners in Recovery

Title: Regional planning and the Implementation of Integrated Mental Health Care: the experience of Partners in Recovery James A Gillespie Introduction. Improved care integration is a core element for improvement of Australia’s mental health services. This requires fundamentally better links between health-focused care and social and community-based supports. The fragmentation of Australia’s health systems – ranging from a public hospital system funded and managed at state level and primary care at federal has created a series of fissures that have proved hard to bridge.  Policy-makers have supported an institutional shift to local and regional action to overcome these historic splits. This paper uses an institutional analysis of the Australian mental health system to identify some long-term elements shaping this continuity. It uses a recent innovative program, Partners in Recovery (PIR), to test the ability of a focused program break through these obstacles. From 2014-19 PIR combined a mental health recovery-based approach with an emphasis on building constructive partnerships between competing mental health providers.  PIR was one of the few initiatives in mental health that specifically aimed to bring together primary health care, mental health and non-health services. Its approach by-passed existing structures and used more flexible, locally based approaches aiming at system change. Theory/methods.  Persistent failures to implement   reform, despite widespread consensus on the need for change suggests deeper, systematic problems. The paper uses public policy institutional theory to identify structural problems facing mental health service integration. A narrative review of available evaluations of PIR programs across Australia assesses the degree action was based on knowledge of local services and problems. How far did each evaluated program identify bridging mechanisms across health and social policy and the mechanisms of ‘partnership’ between funding and delivery agencies in public and private (NFP) sectors? What information was used about local services to shape referral practices? What methods were used to gather information about the pattern of local services? Evidence from Integrated Mental Health Maps produced for PIRs is used to show local differences in services and programs across PIRs. Results. The evaluations had uneven information on the way individual PIRs tackled the problem of local knowledge and how they built referral networks.  Approaches ranged from systematic mapping of mental health services through to more ad hoc or passive methods. Conclusions. The variation in methods make systematic comparisons difficult, but PIRs that started from a systematic approach to planning were less likely to have crises of overload or mismatches between client load and referrals. Lasting institutional changes were difficult due to the instability of the program and its final attempted integration into the very different National Disability Insurance Scheme. Limitations: The research is based on publicly available evaluations and other papers on PIR. These include a national evaluation, but the local evaluations cover only a minority of PIRs. Suggestions for future research: More work needs to be done on how new tools for mapping are used in policy and practice in developing regional and local approaches to service integration.


Summary
-Improved care integration is a core element for improvement of Australia's mental health services. This requires fundamentally better links between health-focused care and social and community-based supports.
-The fragmentation of Australia's health systems -ranging from a public hospital system funded and managed at state level and primary care at federal has created a series of fissures that have proved hard to bridge.
-Policy-makers have supported an institutional shift to local and regional action to overcome these historic splits.
-Partners in Recovery was a briefly successful nationally funded, locally managed program that attempted to improve outcomes for people living with severe and chronic mental illness and achieve system change.

PIR target group
-Around 600,000 Australians experience severe mental ill-health.
-Of these, 60,000 have enduring and disabling symptoms with complex, multiagency support needs.
-PIR focused on 24,000 people within this 60,000 group.
-These people experience persistent symptoms, significant functional impairment, and psychosocial disability.
-They are reported to often fall through the system gaps and require more intensive support.

Partners in Recovery (PIR)
Overall aim of PIR: • To improve the system response to people with severe and persistent mental illness who have complex needs (the target group) • To improve recovery outcomes for those people using the PIR services Did this through: • Prime contractor principal-agent model. Funding devolved to regional Hub organizations and service organization (NGOs with experience in metal health) • Drawing together fragmented services to work in a more collaborative, coordinated, and integrated way.
• Facilitating better coordination; • Strengthening partnerships between services and building better linkages; • Improving referral pathways; and • Promoting a community-based recovery model. . -PIR operational guidelines SFs must "ensure their support facilitation/coordination focus is maintained and not shifted to a case management focus". -The role of the SF was not to 'manage' the consumer (the 'case') but to manage the system. -Job descriptions: "in the main, be a coordinator of the service system, not a 'service deliverer' in the traditional sense; in working to improve the system response to a [PIR] client, engage with and chase up services and supports, build service pathways and networks of services and supports needed" (Stepping Up, 2015) The PIR teams were described with 76 codes of DESDE-LTC system for the standard description of long-term care services (Salvador-Carulla et al, 2013), i.e. some teams delivered more than one type of care (e.g. accessibility and information).
PIR teams were described by using 6 different codes within 3 large care typologies of DESDE-LTC system: A -Accessibility to care: access to care without direct provision of care related to needs (e.g. access to employment) • A4 -Case coordination O -Outpatient care: contact with the person in a limited period of time (e.g. visit with the GP).
• O5.  There is information on professionals for 5 PHN regions (In 2 PHNs a few PIR teams did not report workforce composition)

Professionals in PIR
Australian Capital Territory, Central Eastern Sydney, South Western Sydney, Perth North and Wester Sydney

Evolution of PIR teams in Western Sydney (2014/2019)
Context adapted system PIR teams were described as outpatient services in the Atlas 2014. However, they have been recoded as Accessibility services in the new Atlas 2019. Their previous coding was due to the additional support they had been required to provide at that time. These have now been recoded as Accessibility, the type of care for which they were primarily intended. In this last Atlas, PIR teams have also been provided with an additional Guidance and Assessment code, as they are now supporting clients with assessments for NDIS applications.

Social network analysis: fragile devolved connections
Devolved control without systems change.
-Lasting service connections not developed effectively -Remained focused on the lead agency, relying on Support Facilitators to build local partnerships -Lack of supporting infrastructure : little system preparation or workforce planning'

Conclusions: Governance and Commitment
-Lasting institutional changes were difficult due to the instability of the program and its final attempted integration into the very different National Disability Insurance Scheme.
-Implementation studies need to understand systems and governance context The main objective of the PIR program is to increase the accessibility to a different range of services for people with a lived experience of mental illness Interestingly, though, these providers are not just focused on accessibility, but take a more holistic approach, providing also some counselling.
Theoretically, the code of the PIR program should be an A4 (accessibility/care manager), but some organisations in other regions report that they are providing more intensive direct day care, so they received an outpatient code (O5.2). They can meet according to the needs of the consumer, with the capacity of meeting them on a daily basis if needed in the first stage of the program.
Studies on the effectiveness of PIR in this region show that despite issues with program stability caused by changing government priorities (Smith-Merry, Gillespie, Hancock, & Yen, 2015), this service has assisted in reducing the level of unmet need and promoting recovery (Hancock, Scanlan, Gillespie, Smith-Merry, & Yen, 2018).
Our coding of PIR, which in 2014 reflected the extension of its role in the region to include outpatient care as needed, is in this atlas reflective of its additional assessment capacity to assist people with the transition to the NDIS. This capacity to respond to changing community need is a demonstration of self-adaptation within the system as outlined in the introduction to this discussion: that is, while the service may have deviated to some extent from its ascribed core function, it has been able to identify and effectively respond to changing need in its environment.