Contents
New approach to models of care.
Part A: Findings of the Evaluation
3. The national policy context
4. Background and overview of the FaHCSIA targeted Community Mental Health Initiatives
6. Client outcomes from FaHCSIA's mental health initiatives
Outcomes for clients of Personal Helpers and Mentors Service
Outcomes for clients of Mental Health Community Based Services
Outcomes for clients of Mental Health Respite
7. Service outcomes: effectiveness of services against principles of good service practice
Responsive, relevant, user friendly services
Thorough client needs assessment and effective case management
Holistic services—providing a wide range of assistance to clients
Effective networking, collaboration and practical working links with services
A family focus to models of care
Conclusions on outcomes from mental health service initiatives
9. Policy and system factors affecting service achievement
Service size, capacity and sustainability of services
Service capacity in the regional (rural and remote) areas
Geographical boundary restrictions on eligibility
Possible future directions for FaHCSIA under the Fourth National Mental Health Plan
10. Findings that guide the future policy approach of FaHCSIA
New approach to models of care
Nature and extent of the problem
Current policy context and emerging national system and service issues
Current and emerging service needs for people with mental health problems
Components and underpinnings for effective reform
Partnerships and collaboration
B1. Snapshot of individual initiatives—The Personal Helpers and Mentors Initiative
B2. Snapshot of individual initiatives— Mental Health Community Based Services
Information sources for this overview
Mental Health Community Based Services in operation
Client perspectives on the Mental Health Community Based Services
Service provider perspectives on client outcomes
About Mental Health Community Based Services
Issues arising for Mental Health Community Based Services
Overall assessment of Mental Health Community Based Services Effectiveness
B3. Snapshot of individual initiatives—Mental Health Respite Services
Objectives of the Mental Health Respite Initiative
The Mental Health Respite Services in operation
Client perspectives on the MHR initiative
Service provider perspectives on client outcomes
About Mental Health Respite Services
Brokerage and NRDF arrangements
Quality of and access to services
Achievements of the Mental Health Respite Initiative
Issues arising from current mental health respite policy and service design
D. Mental Health Program Evaluation Advisory Committee
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Graphs
Figure 1: Outcomes for Personal Helpers and Mentors Services clients
Figure 2: Outcomes for clients in Mental Health Community Based services
Figure 3: Outcomes for clients in Mental Health Respite services
Figure 4: Different types of partnering relationships and purposes
Figure 5: Types of collaboration by PHaMs services
Figure 6: Types of collaboration by Mental Health Community Based services
Figure 7: Collaboration between service types—PHaMs
Figure 8: Collaboration between service types—Mental Health Community Based Services
Figure 9: Collaboration between service types—Respite
Figure 10: Most commonly held qualifications in Personal Helpers and Mentors Services
Figure 11: Most commonly held qualification in Mental Health Community Based services
Figure 12: Most commonly held qualification in National Respite Development Fund services
Figure 13: Most commonly held qualification in brokerage services
Figure 14: Measures to ensure quality of service—Mental Health Respite
Figure 15: Degrees of family focus
Figure 16: System program theory
Figure 18: People with a drug and alcohol co-morbidity in PHaMs services
Figure 19: People with mental health and an intellectual co-morbidity in PHaMs services
Figure 20: People in PHaMs services who have previously been institutionalised or incarcerated
Figure 21: Indigenous people and people from a CALD background in PHaMs services
Figure 22: Outcomes for clients in PHaMs services
Figure 23: Numbers of clients in PHaMs services
Figure 24: Staff numbers in PHaMs services
Figure 25: Services that PHaMs services work with
Figure 26: Percentages of referrals from GPs and community services to PHaMs services
Figure 27: Percentages of self-referrals to PHaMs services
Figure 28: Types of collaboration by PHaMs services
Figure 29: Reasons for difficulties in recruiting staff for PHaMs
Figure 30: Challenges in retaining staff for PHaMs
Figure 31: Most commonly held qualification in PHaMs services
Figure 32: Measures to ensure quality service in PHaMs
Figure 33: Number of peer support workers in PHaMs
Figure 34: Methods of managing demand—PHaMs
Figure 35: Indigenous and CALD background clients in Mental Health Community Based services
Figure 36: Outcomes for clients—Mental Health Community Based Services
Figure 37: Number of clients in Mental Health Community Based Services
Figure 38: Numbers of staff in Mental Health Community Based Services
Figure 39: Services that Mental Health Community Based Services work with
Figure 40: Referrals from GPs to Mental Health Community Based Services
Figure 41: Types of collaboration by Mental Health Community Based Services
Figure 43: Challenges in retaining staff for Mental Health Community Based Services
Figure 44: Most commonly held qualification level in Community Based Initiative Services
Figure 45: Methods of managing demand—Mental Health Community Based Services
Figure 46: Percentage of Indigenous clients in MHR services
Figure 47: Percentage of CALD background clients in MHR services
Figure 48: Outcomes for MHR clients
Figure 49: Numbers of clients in MHR services
Figure 50: Number of staff in MHR services
Figure 51: Services that MHR services work with
Figure 52: Reasons for difficulties in recruiting suitable staff—MHR
Figure 53: Most commonly held qualification in NRDF services
Figure 54: Most commonly held qualification in Brokerage services
Figure 55: Measures taken by Respite services to ensure quality of service
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EXECUTIVE SUMMARY
Purpose
This project was designed to achieve two broad objectives:
- To assess the performance of the Department of Families, Housing, Community Services and Indigenous Affairs' (FaHCSIA) Targeted Community Care Mental Health Initiatives to date, to determine changes that would enhance service policy and program design, so the initiatives can achieve optimal results.
- To consider the role of FaHCSIA's Targeted Community Care Mental Health Initiatives within the broader mental health sector and how the suite of programs integrate and complement other services—focusing on policy direction.
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Terms of reference
The evaluation of the Targeted Community Care Mental Health Initiatives was designed to achieve the following outcomes and inform future developments in policy and program development:
- capture the impact of the programs 1 to date on individuals with a mental illness, their families and carers
- capture what each program has achieved individually and what the suite of programs has achieved
- identify the synergies between programs and how they align
- review the current service delivery models for each of the three programs and make recommendations on the way forward for each
- consider the role of the Targeted Community Care Mental Health Initiatives within the broader mental health sector and how the suite of programs integrate and complement other services, with a specific focus on considering future policy direction
- report on management issues which support or detract from program efficiency and effectiveness.
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Methodology
The evaluation process and survey questions were designed with FaHCSIA's Mental Health Branch.
A mixed methods approach, involving a range of activities, enabled systematic, objective and rigorous data collection and analysis. The activities included:
- a workshop to elicit program theory in relation to changes sought for clients;
- a comprehensive literature review.
- interviews with key stakeholders from FaHCSIA, the Department of Health and Ageing (DoHA), all state and territory governments and a range of relevant peak bodies;
- visits to funded services provided under each initiative to gather, interview managers and staff and interview with clients for insights on their service experience during project implementation;
- telephone interviews on services with the interview sample not visited;
- review of contracts and reports for all services provided; and
- an online survey covering all services in the three initiatives to provide a quantitative evidence base from the service perspective.
- Only triangulated data were used to inform evaluation recommendations.
1 -Since the development of these Terms of Reference the language used to refer to the Targeted Community Care (TCC) Program and its three community mental health initiatives has changed. The term "program" in these Terms of Reference is used to refer to each of the three individual initiatives under the TCC Program.
Limitations of the methodology and approach
- The evaluation was strategic and encompassed three initiatives as well as relevant policy related research. Its overall conclusions do not apply to each individual project funded or each service stream. However, the evaluation does draw considerably on information available from the projects, information from FaHCSIA representatives and stakeholders, as well as relevant literature.
Client outcomes
Clients who have accessed services under all three initiatives are achieving significant outcomes in line with the objectives of the program and client personal plans. These outcomes include:
- improved health and wellbeing resulting from improved ability to connect with services (including health services), improved personal coping and problem solving skills and increased confidence to manage their own lives and their mental health;
- reduction in the risks of mental illness through timely action on high risk behaviours and situations;
- reduction in hospital admissions, recurrence of severe mental illness and high use of health services, particularly hospitals and acute care services; and
- improved ability to lead fulfilling lives.
Access by clients of Indigenous and Culturally and Linguistically Diverse (CALD) target groups are much lower than hoped. Many systemic and cultural barriers remain, which are largely outside the control of services.
Achievements of the mental health initiatives
Despite only being recently established, each of the Targeted Community Care Mental Health Initiatives are demonstrating quality service and making a substantial contribution to the service system by increasing access to services, improving service pathways and ensuring social inclusion.
- Personal Helpers and Mentors (PHaMs) is seen as highly effective by clients and all stakeholder groups and it has made visible contributions to those with severe and persistent illness. Minor evolution in the program design and funding levels would substantially increase its effectiveness. More than 6,600 clients had been assisted by PHaMs by November 2009.
- The Mental Health Community Based services (MHCB) are also making a major contribution, having integrated well with other services and providing high quality services for families and young people. MHCB services are generally provided based on sound evidence and contribute to the overall evidence base for mental health promotion, prevention and early intervention through evaluation work. These services have been effective in prevention and early intervention and constitute high value in terms of payback for investment. However the size of the program means that its reach is limited. More than 7,300 clients had been assisted by MHCB by November 2009.
- The Mental Health Respite Initiative (MHR) is providing essential services by carers who access it, but in many areas it is not reaching adequate numbers of clients who are carers for those who have a mental illness or in providing the spectrum of care required. It would benefit from simplification, changes to eligibility and changes to the service delivery system so more coherent approaches to care can be supported. A total of 19,000 clients had been assisted by MHR by November 2009.
Service delivery models
The initiatives exhibit many synergies in objectives, approaches and models of care. Where services are within reach of each other regionally there is extensive cross referral between them. The extent of this depends on the capacity of the service, the other services that are available and the quality of the relationship between services.
All three initiatives are making a case to respond to family needs rather than just individual client needs to serve mental health clients and carers more effectively and make a larger contribution to health promotion, prevention and early intervention.
Services exhibit high quality engagement and strong compliance by clients to agreed individual programs. This was confirmed through client interviews, case studies and reports by stakeholders (such as other services and family members).
The role of FaHCSIA's mental health initiatives in the mental health effort
Apart from PHaMs, the Targeted Community Care Initiatives (including rationale) are not well known to, or understood by, Australian state and territory governments or key stakeholders. The initiatives need to be communicated more coherently and cogently so all stakeholders understand their rationale, what is being offered, and how the suite of initiatives support the national mental health effort. To address these issues, stakeholders are calling for a FaHCSIA community mental health plan.
Policy direction and FaHCSIA's role under the national mental health plans
FaHCSIA is seen as providing leadership in and impetus to psychosocial rehabilitation Non-government sector stakeholders welcomed FaHCSIA's involvement and regard it as consistent with and complementary to the large number of prevention, early intervention and targeted support programs already provided through other Australian Government and state and territory government programs.
Whole-of-government effort is being adversely affected by varying interpretations of the term 'community mental health'. Community mental health services manage a large spectrum of services for mental health clients from the traditional 'step up, step down services' and other individual clinical support to psychosocial approaches which improve the capacity of individuals affected by mental health problems to maximise social and economic participation. It is not always understood that FaHCSIA offers psychosocial services only.
FaHCSIA and the community service sector have much to contribute to the implementation and continuing policy and strategy development associated with the Fourth National Mental Health Plan:An agenda for collaborative government action in mental health 2009–2014. FaHCSIA should play anactive role in improving the understanding of the role of the community mental health sector in addressing social determinants of mental health and supporting its development.
Management of the mental health initiatives
Management of the mental health initiatives is regarded positively compared to programs funded by other agencies. The flexibility to meet needs is valued highly and there is a strong sense that FaHCSIA understands the business of mental health service delivery. However modifications to initiative management is required to increase efficiency and effectiveness. The MHR needs to be redesigned.
While the initiatives have benefited targeted groups, they have been implemented within a very complex service system. States and territories are concerned that the initiatives—because of insufficient consultation—are not being integrated optimally within the service system. These levels of government believe more consultation on the planning of service placement and more consultation with FaHCSIA on ongoing planning management issues is needed. Key Non-Government Organisation (NGO) service providers have echoed the need to be involved in service planning effort because of their local and regional knowledge of the services and systems offered both by the community sector and government.
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Recommendations
New approach to models of care
Rather than having separate initiatives covering specific target groups consider a single initiative covering all target groups with services individually or collectively providing a range of supports appropriate to specific client and family needs.
All services should incorporate family approaches in their service structure.
For all initiatives
Postcode and other boundary restrictions should be removed and replaced with appropriate service access guidelines on service area. This will allow for service judgment based on the other service structures, the individual situation of applicants and allow a more responsive service. It would also allow services to negotiate with other services to meet needs. Guidelines should place responsibility to report on how much of a service area is supported and what areas are not served.
Review the funding arrangements with a view to enabling more effective service delivery for:
- service travel and staff allocation to support outreach especially where large geographical areas are served;
- staff time required to support collaborative effort at the regional and service levels.
For individual service delivery models
For PHaMs
- relax the eligibility restrictions relating to the timing required for clients to agree to confidentiality and data sharing, allowing the service to make a judgment based on individual circumstances;
- relax the eligibility restrictions for timing for undertakings to address concurrent alcohol and drug morbidity, allowing the service to make judgments based on individual circumstances;
- explore whether the EST should be supplemented with an additional client outcomes monitoring system.
For MHCB
- consider expanding the capacity to support families and children using existing MHCB approaches;
- develop a strategy to take up the outcomes of innovative effort and use services more strategically for service capacity building for prevention and early intervention approaches for young people and families.
For Respite
- replace the term 'respite' with the term 'carer support';
- simplify the service model with an orientation on meeting client (and family) needs;
- support the development of client-centered care approaches by using principles and objectives to guide effort;
- expand the eligibility criteria to encompass young carers in a primary or secondary caring role;
- ensure that carers have access to a suite of support services in a region with expanded access to planned and flexible respite services—these should encompass at least the full range of supports available now;
- encourage innovation by services to support assertive engagement of carers and publicise effective strategies across Australia;
- expand respite delivery outlets so other community-based mental health services—for example, MHCB and PHaMs—can access funding to support carers.
Service system
Regional service planning should be undertaken in consultation with states and territories, providers and regional NGOs with a view to:
- building effective service collaborations, including through inter-service contractual arrangements;
- linking with other FaHCSIA funded services;
- improving the sustainability and capacity of services based on an analysis of the critical requirements for an effectively functioning sustainable service;
- contributing to national collaborative efforts and service pathway development.
Develop a strategy for the building of capacity to meet the needs of targeted groups
This should consider changing the orientation of services to have a family oriented approach, the building of staff capacity and building the capacity of Indigenous and CALD representative groups to work in partnership with mainstream services. This strategy should incorporate attention to effective models which have been developed through existing mental health services.
FaHCSIA—strategic leadership
Develop a strategic policy and plan for community mental health
FaHCSIA should develop a mental health and wellbeing plan to clarify the role of various programs that contribute to mental health and wellbeing and develop policy and service connections to improve the enabling environment and lead to better health outcomes.
The plan should outline appropriate advisory structures involving service provider networks, client groups and peak bodies.
FaHCSIA should use peak bodies as capacity building partners, for example, through a more organised and strategic effort in gaining their assistance for particular target groups and building capacity for them to work collaboratively. A broad suite of interests should be included.
Adopt a strategic approach to workforce development
At system level identify needs and priorities and policy and system support for an organised approach to workforce development:
- Develop strategies which incorporate attention to building the capacity of the service system to work more collaboratively, especially for cross sectoral and multi-disciplinary collaboration;
- Improve access to inexpensive; accessible timely training nationally with rural and remote area needs a priority. Consider the use of an e-platform or use of existing platforms. Investigate the use of existing courses and resources produced by peak bodies and services for rapid deployment. Explore how existing capacity can be used to support the community mental health system level (for example, the Mental Health Pod);
- Develop assertive approaches to build the capacity of particular groups with Indigenous and CALD workforce a priority;
- Consider leadership development to as a strategy to build mental health sector capacity.
Develop a research strategy to underpin policy and service priorities
Undertake priority driven research to support thinking on policy and service models, particularly for rural and remote areas, and to support contribution to thinking for the development and implementation of the Fourth National Mental Health Plan.
Initial areas for priority driven research include:
- the need for, and approaches to, legislative reform;
- service pathways (for example, the elements of effective referral systems between health and community services and effective partnerships between the community service sector and health);
- roles and needs of services—service capacity needs, develop a clearer understanding of what 'clinical' entails in the service context and how the needs of Indigenous and CALD communities can be better served;
- the strategy should incorporate systematic evaluation of models of care:
- document existing practices and evaluate from a range of perspectives;
- undertake cost benefit studies of recovery models;
- follow up of those who receive interventions, especially to assess the benefits of early intervention, and how that might be followed up at transition points;
- evaluate innovative local approaches as possible models for replication elsewhere, for example, family based services as a means of addressing co-morbidity;
- pay special attention to developing more effective models for rural and remote services where the service environment is less extensive.
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PART A: Findings of the Evaluation
Structure of the Report
This report is divided into three parts. Part A provides the main findings of the evaluation and summarises recommendations. Part B provides detailed recommendations for the way forward for FaHCSIA under the Fourth National Mental Health Plan. Part C details the evaluation's methodology, describes the findings for each program, the stakeholder consultations and governance of the evaluation, as well as the evidence in the literature informing these findings.
The chapters are as follows:
Executive Summary
Part A: FINDINGS OF THE EVALUATION
- Introduction and background
- Purpose of the evaluation
- Methodology
- The National Policy Context
- Overview of the FaHCSIA Targeted Community Mental Health Initiatives
- Key Findings
- Client outcomes from FaHCSIA Community Mental Health Initiatives
- Service Outcomes: Effectiveness of services against good practice principles
- Models of Care
- Policy and system factors affecting services achievements
Part B: THE WAY FORWARD
- Findings that guide the future policy approach of FaHCSIA
- Recommendations
Part C: LITERATURE REVIEW & SNAPSHOTS OF INDIVDUAL INITIATIVES
- Literature review
- Snapshot of Individual initiatives (this contains more detailed information on each Mental Health Initiative
- Schedule of consultations
- Evaluation Advisory Committee
- The Terms of Reference for the Evaluation
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INTRODUCTION
1. Purpose of the evaluation
The purpose of the evaluation was to provide information and recommendations that will assist with policy and strategy development of FaHCSIA community Health Initiatives.
FaHCSIA has responsibility for three of the 19 mental health programs under the Council of Australian Health Ministers'/Council of Australian Governments (COAG) Fourth National Mental HealthPlan: An agenda for collaborative government action in mental health2009–2014, released in November, 2009.
Under the plan FaHCSIA has responsibility for three Targeted Community Care Mental Health Initiatives:
- PHaMs—using recovery approaches to serve individuals with severe functional limitations arising from mental illness;
- MHCB—a health promotion, prevention and early intervention initiative targeted to the needs of children and families;
- MHR—serving the needs of carers while taking into account the needs of care recipients and divided into a brokerage component and the National Respite Development Fund (NRDF).
More detail on these initiatives in section 4.
Terms of reference 2 for the evaluation
The evaluation of the Targeted Community Care Mental Health Initiatives was designed to achieve the following outcomes and inform future developments in policy and program development:
- capture the impact of the programs to date on individuals with a mental illness, their families and carers;
- capture what each program has achieved individually and what the suite of programs has achieved;
- identify the synergies between programs and how they align;
- review the current service delivery models for each of the three programs and make recommendations on the way forward for each;
- consider the role of the Targeted Community Care Mental Health Initiatives within the broader mental health sector and how the suite of programs integrate and complement other services, with a specific focus on considering future policy direction;
- report on management issues which support or detract from program efficiency and effectiveness.
The evaluation process and survey questions were designed with FaHCSIA's Mental Health Branch.
2 - Since the development of these Terms of Reference the language used to refer to the Targeted Community Care (TCC) Program and its three community mental health initiatives has changed. The term "program" in these Terms of Reference is used to refer to each of the three individual initiatives under the TCC Program.
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2. Methodology
The methodology used for the evaluation to answer the terms of reference is set out below.
Consultation and regular reporting with FaHCSIA representatives
Interviews and regular meetings with key FaHCSIA staff were conducted throughout the course of the evaluation.
A Mental Health Program Evaluation Advisory Committee was established to provide guidance on the evaluation. The Advisory Committee met three times during the course of the evaluation. A list of committee representatives are provided in Part C: Mental Health Program Evaluation Advisory Committee.
Data collection
The timetable and budget for the evaluation dictated the sample size of providers who would receive a site visit and be consulted in detail. Some consultations were extended to two days. To minimise the effect of unintended bias in the sample we used multiple methods of data collection so the data could be triangulated in analysis. The main data collection methods used were:
- desktop research, document and literature review;
- site visits to a selection of providers in each initiative and each state;
- an online survey of service providers;
- consultation with other key stakeholders.
Each of these methods of data collection is described in more detail below.
Desktop research and document review
A comprehensive range of documentary sources (progress reports, internal and external reports, contracts, websites, online searches, white and grey literature) were analysed against the terms of reference. The results guided the consultative processes and informed, validated and supported the findings drawn from interviews with all service providers, service recipients and stakeholders.
Service provider/service recipient interviews
Visits to services were made to develop an understanding of how funded projects were operating against contract conditions. Selection of service for visits was based on the following criteria: all initiatives, all states and territories, metropolitan and rural selection (limited by travel budget and time).
Staff at the executive, middle and operational levels were interviewed on how they delivered services, the nature of the clients targeted, the nature of collaboration with other services, and the issues that most influenced service delivery. Clients were also interviewed—individually, face to face, by telephone or in groups. A summary of the service provider/service consultations is provided in Part C: Services and stakeholders consulted.
Interviews with key stakeholders
Interviews (telephone and face-to-face) were conducted with other key stakeholders including representatives of COAG, State Government Mental Health personnel, state health departments and peak body representatives. A summary of these key stakeholders is included in Part C: Service and Stakeholders Consulted.
Survey of service providers
An online survey was developed and piloted with a service provider from each of the three initiatives. The survey comprised quantitative and qualitative questions grouped into eight broad categories—organisational information, characteristics of the program target group, approach to service, relationships with other services, workforce, access to services, outcomes from the service, and management of the program.
The survey was made available to representatives of all service providers across all three initiatives over a period of several weeks. To assist with maximising the response rate two reminder notices were sent to service providers and two extensions of time provided.
The response rates were: 72 per cent for PHaMs, 55 per cent for MHR and 54 per cent for the MHCB.
Data analysis
Quantitative and qualitative data were collated and analysed thematically.
Regular quality checks of all data and information sources was undertaken by the evaluation team throughout the evaluation to assess the reliability of the findings, establish emerging themes and establish if further lines of enquiry would be appropriate.
Limitations of the methodology and approach
The evaluation is strategic and encompasses three initiatives as well as relevant policy related research. Its conclusions do not apply to each individual project funded. However, the evaluation draws considerably on information available from the projects, information from FaHCSIA representatives and stakeholders, as well as relevant literature.
Information about outcomes is qualitative and not based on formal measures of cases. However, examination of systems on service visits indicates it is likely that most projects administered by PHaMs and MHCB can provide such measures. This information, while useful for commenting on the types of outcomes that the projects and the program as a whole are having, is not as useful for drawing conclusions about how widespread the outcomes are. Another limitation is that the evaluation did not include a large sample of rural and remote services for a range of reasons, including length of time since service establishment and resourcing and timing constraints. As well, there are no benchmarks against which to compare these initiatives with others.
Impressions of client outcomes have also come from clients who have agreed to be interviewed. As they are generally positive experiences the risk of positive bias is always present. Measures to balance these impressions included using open ended questions, encouraging clients to relate factual information as well as stories, and triangulating impressions with stakeholders such as family members, carers and other contributing service providers.
Clients described these steps quite clearly and the consultancy teams were assured that reported outcomes are representative because of the number of clients and the repetition of themes.
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3. The national policy context
Extent of mental illness
Mental health is one of Australia's major health issues with significant personal, social and economic implications. The 2007 national survey of mental health and wellbeing conducted by the Australian Bureau of Statistics found that an estimated 3.2 million Australians (20 per cent of the population aged between 16 and 85 years) had a mental disorder in the 12 months prior to the survey. The study of Disease and Injury in Australia indicated that mental disorders constitute the leading cause of disability burden in Australia, accounting for an estimated 24 per cent of the total years lost due to disability. 3
The impacts of mental illness on the community are widespread and it is likely that significant levels are unrecorded. The most visible impact is on the health and community services systems with significantly higher costs to the community service system. 4
Many of these costs are hidden and others not easily quantifiable. Carers, for example, make a significant contribution at much personal cost—including the loss of finances, careers, social connectivity, health problems and being able to pursue personal lifestyle choices—and many do not self identify, with a subsequent loss of entitlements.5 Individuals also suffer the loss of education and employment opportunities, suffer stigma and social isolation and are hampered in their efforts to participate fully in Australian society and the economy.
Causes of mental illness and effective interventions
The causes of mental ill health are complex and varied. Biomedical factors play a significant role in most clinically diagnosed mental illness. However social factors play a large part in the origins and progression of depression, the most common form of mental illness, and preventive approaches recognise that appropriate social interventions play an important role in minimising the progression from risk of illness to actual illness. Chronic physical illnesses are closely linked with depression and other mental health problems. Mental illness is also highly associated with family breakdown, substance abuse and homelessness. Economic factors such as unemployment are also frequently linked with mental illness. Social isolation for individuals or groups is a major contributor.
All Australian Governments have recognised that effective community support services, complemented by high quality clinical and health oriented services for individuals, are essential to deal effectively with these problems.
This approach aligns with the Australian Government's emphasis on social inclusion approaches that address complex social issues such as homelessness and inequity in social outcomes. The community mental health initiatives administered by FaHCSIA adopt community mental health models to address the basic needs of people with mental illness, their families and carers. These initiatives build on the strengths of individuals and communities, reinforce collaborative partnerships between the community and clinical sectors, tailor services to the needs of individuals, families and carers, and build resilience and capacity. This holistic approach to mental health recognises the interrelationship between biomedical and social determinants of health thus blurring the boundaries between traditional health and community service models.
It is well accepted that social and community-based approaches to care for people with mental health conditions should underpin population level approaches, augmented by clinical and other professional supports as appropriate. The notion of 'recovery' is important in any policy for mental health care: people with mental illness are supported to live as normal as possible a life with their illness. Family, carers and other social role models are crucial supports in any effective care arrangement.
3 - Australian Institute of Health and Welfare (AIHW) 2008. Mental Health Services in Australia 2005–06. Mental health series no.10, cat no HSE 56 Canberra: AIHW.
4 - National Mental Health Report 2007: summary of Twelve Years of Reform in Australia's Mental Health Services under theNational Mental Health Strategy 1993–2005.
5 - Commonwealth of Australia 2009, 'Who Cares...? Report on the inquiry into better support for carers.'
System issues
Traditionally mental illness has been regarded as a health problem and policies and funding have concentrated on health sector responses. The deinstitutionalisation of mental health care in the latter decades of the 20th century was not accompanied by recognition of the need commensurately to improve access to community supports and for economic support through low cost housing and assistance with finding employment.
Mental health services have consequently continued to be professionally driven, with funding supporting a focus of clinical interventions6 in isolation from clients' broader social context. Shortages of mental health professionals and patient difficulties in accessing these services have been compounding factors.
Consequently, there has been little engagement by the health sector with government agencies responsible for welfare, employment and housing programs. The lack of whole of government approaches at both Australian and state levels has been highlighted in several major reviews. Uncoordinated government approaches have particularly disadvantaged people living in rural and remote areas and Indigenous people. Other at risk groups, such as young people, have also often been beyond the reach of traditional health services (including general practice and hospital-based services).
However all governments have had a long standing commitment to mental health reform. The National Mental Health Strategy (commenced in 1992 and revised in 2008) provides a whole-of-government and whole-of-community framework for national reform, including the delivery of appropriate clinical and non-clinical based care across the lifespan.
6 -National Mental Health Report 2007: summary of Twelve Years of Reform in Australia's Mental Health Services under the National Mental Health Strategy 1993–2005.
Current policy agenda
Current policy follows the National Health Reform Agenda set out in The COAG National Action Planon Mental Health (2006–2011) and the Fourth National Mental Health Plan (2010–2014) (part of theongoing National Mental Policy). These policies embrace the following key approaches:
- significant new funding for mental health services and support;
- a whole-of-government approach within and across jurisdictions;
- at Australian Government level, engagement of three key agencies—the Department of Education, Employment and Workplace Relations (DEEWR), FaHCSIA and DoHA;
- an increased emphasis on community mental health;
- an emphasis on prevention.
All governments are committed to working together to achieve four defined outcomes:
- reducing the prevalence and severity of mental health problems in Australia;
- reducing the prevalence of risk factors that contribute to the onset of mental health illness and prevent longer term recovery;
- increasing the proportion of people with an emerging or established mental illness who are able to access the right health care and other relevant community services at the right time, with a particular focus on early intervention;
- increasing the ability of people with a mental illness to participate in the community, employment, education and training, including through an increase in access to stable accommodation.
Challenges for national policy and strategy
While national policies are responding to needs and setting the agenda for change, significant challenges remain for governments in achieving the policy objectives and improving mental health outcomes. The roles of key agencies in the Australian Government (DoHA, FaHCSIA and DEEWR) and between the Australian Government and the states and territories still need exploration and development.
Of key concern is that there are insufficient services to meet needs at all levels. While significant additional funding has been made to the community sector there are concerns within the sector both as to its sufficiency and to its continuation. The Australian Government's 2007 mental health report showed a significant imbalance of funding towards traditional clinically-based services and there is concern as to the long-term commitment to redressing this imbalance. In particular, many services are concerned about the short-term nature of funding contracts with consequent problems around service planning, continuity of care and attracting and retaining skilled staff.
The service system is fragmented and the range and distribution of services is patchy across the nation with rural and remote areas particularly problematic. The services system is difficult to negotiate for clients with poor connections between curative and community services. Traditional service patterns have largely been clinically driven and socially disadvantaged areas, even in major cities, are not well served. Particular at risk groups such as youth, homeless and people with substance abuse problems are disadvantaged by their difficulties in accessing available specific mental health services. Effective supports for Indigenous people are lacking in both urban and rural/ remote areas. The needs of culturally and linguistically diverse groups are also not well met.
The lack of a diverse, well-trained and appropriately distributed workforce is a major barrier to effective service improvement. Many health professionals and health services do not regard those working in social support services as suitably skilled to provide effective care. Team based approaches involving both clinicians and support workers are uncommon. Significant investment in education and training will be required to overcome these barriers over time. These difficulties inhibit more innovative service models that better integrate community and clinical supports.
Attempts to achieve whole-of-government approaches are at early stages. New paradigms of care which incorporate concepts of holistic care combining clinical interventions with psychosocial interventions which address the social determinants of health challenge mental health practice systems. International evidence shows that it is particularly difficult to bring the providers of clinical services into whole-of-government approaches. Health services tend to be professionally dominated and focused on the immediate imperatives of meeting the demands for acute clinical care. Consideration of broad social determinant issues, such as affordable housing and employment, are therefore seen by most clinicians as outside the scope of care and of influence.
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4. Background and overview of the FaHCSIA Targeted Community Mental Health Initiatives
Mental Health Initiatives: FaHCSIA's mental health program
In 2006–07 the Australian Government Budget provided funding for 19 COAG mental health initiatives to enhance clinical mental health services and community support services as part of the National Action Plan. In addition, individual state and territory jurisdictions provided funding for a range of mental health initiatives as part of the individual implementation plans linked to the National Action Plan.
These initiatives were a response to awareness of the major gaps in the way services were provided to people with a mental illness, their families and carers. The changes were prompted by an evaluation of the Second National Mental Health Plan (2003) and the Senate Inquiry into Mental Health Services in 2006.
Personal Helpers and Mentors, Mental Health Community Based services and Mental Health Respite are initiatives funded under the COAG National Action Plan. The three initiatives seek to improve services available to individuals, families and carers affected by mental illness.
Each of FaHCSIA's Mental Health Initiatives adopts a different service delivery strategy designed to meet the particular needs of its target group.
- Personal Helpers and Mentors is a voluntary initiative for participants. It adopts a strengths-based, recovery approach to supporting people with a severe functional limitation resulting from mental illness. The strengths-based component uses a person's strengths rather than focusing on deficits. The recovery component recognises that a person can live a satisfying and contributing life within the limitations caused by their illness. Recovery does not mean cure.
The program aims to foster each individual's sense of whole and dignity and capacity for resilience through stages of recovery. It aims to underpin three key outcomes:- increased access to appropriate support services at the right time;
- increased personal capacity and self-reliance;
- increased community participation.
- mutual respect and compassion between participants, personal helpers and mentors, families and carers where relevant;
- empowerment of participants;
- strong relationships and trust between participants and personal helpers and mentors, which extends to families and carers;
- commitment to achieving positive outcomes of participants; -- flexibility in providing support to participants;
- collaboration between key partnerships, including the participants themselves, families, carers and other service providers to provide holistic support to participants;
- involvement of participants, families and carers in service planning and evaluation.
- Mental Health Community Based Services funds targeted projects to support families, carers, children and young people (aged 16 to 24 years) affected by mental illness. It adopts a flexible model of service delivery to provide each project with the flexibility needed to address the complexity of mental health needs in different ways.
Outputs are:- projects that are able to demonstrate how they will use and develop evidence and/or expand on previous learnings that can be more broadly applied;
- coping skills courses/workshops;
- parenting skills courses for parents and carers of children with mental illness;
- resource and advice services;
- support networks/groups in regional/remote areas;
- mentoring programs;
- community engagement programs;
- community awareness programs, targeting local communities, or specific culturally and linguistically diverse or Indigenous communities;
- preventative programs that enable communities to identify the early warning signs of mental illness and offer support.
The following principles underpin the initiative design:
- Family members and carers affected by mental illness are in need of assistance to effectively fulfil their role. It is important to recognise that families, carers, children and young people providing care also have their own needs and issues to attend to. They can experience confusing and overwhelming feelings such as stress, anxiety, depression, concern, and frustration in their caring role. Family members need adequate education and support from within the community to help them to manage.
- Family members and carers, who are educated, trained and feel supported are better positioned to provide more effective support themselves. This contributes to the long-term mental wellbeing and rehabilitation of the person with a mental illness, including improving medication compliance, reducing relapse, and promoting recovery.
- Having the skills and knowledge more broadly in the community enables people to better identify the early warning signs of a mental illness and offer support and early intervention. Preventative steps taken in a community to identify mental health issues can greatly reduce the overall impact of mental illness on a community in the longer term.
- Mental Health Respite Service adopts two separate service delivery models to provide a range of flexible respite options for carers of people with severe mental illness/psychiatric disability and carers of people with intellectual disability. These include:
- A brokerage service model provided across Australia in 54 Home and Community Care (HACC) regions using the existing network of Australian Government Respite and Carelink Centres. This model is designed to enable carers, the care recipient and their families to have the maximum choice and flexibility tailored to their specific respite needs.
- A direct funding model using the National Respite Development Fund (NRDF). This is designed to identify and fund a range of flexible, innovative respite options for carers of people with mental illness/psychiatric disability and carers of people with intellectual disability that respond to the needs of different regions across Australia.
The design of MHR was informed through consultations. The following elements were identified through the consultations and incorporated into the design of the program:
- flexibility and choice for carers;
- tailored respite options to the needs of carers and the care recipient;
- respite options that are appropriate to the specific needs of the care recipient;
- support services to build relationships of trust with carers and the care recipient;
- early access to respite to minimise emergency or crisis situations;
- correct the undersupply of respite services in many regions across Australia prevent many support services from providing assistances for carers.
As identified in the program guidelines, the perceived outcomes for services are:
- outcomes for carers (carers experience a short-term break from their caring role);
- a service for carers (carers receive a service appropriate to their needs);
- a service for the people for whom they provide care (a care recipient receives a service appropriate to their needs).
The following outputs of service delivery for carers and care recipient involvement— support carers and provide access to information:
- recognise the importance of readily accessible and comprehensive information which facilitates a carer's ability to make informed choices about their caring role;
- help carers gain access to support and assistance, particularly respite care that is appropriate to their needs and the needs of the care recipient;
- ensure practical advice and support for family carers is an integral part of respite services;
- promote and publicise the services to ensure hidden carers are aware of them.
All of FaHCSIA's Targeted Mental Health Initiatives have been implemented with the final phases of PHaMs rolling out as planned.
Out of scope: Activities that are out of scope for the FaHCSIA program are those involving clinical diagnosis of whether a person has a mental illness and those directly providing acute clinical and hospital care. Once people have been identified as having mental illness, FaHCSIA initiatives operate through early intervention to assist with coping with mental illness in the community, mitigating the impacts of mental illness and in some cases assisting with recovery.
Client numbers serviced
The numbers of clients serviced by providers varies considerably between the three initiatives and this reflects the relative intensity of the services. The following figures represent the number of services provided to clients at the end of November 2009:
- the majority of the PHaMs services have around 50 clients. Total—6603 clients.
- approximately one-third of MHCB providers have fewer than 50 clients, another third have between 50 and 100, with the remainder having more than 200 clients. Total—7,300 clients.
- the national respite development fund providers for MHR generally each have around 40 to 50 clients while the brokerage providers have much larger numbers (the majority each have well over 100 clients). Total—19,000 clients.
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5. Key findings
Client outcomes
Clients who have accessed services under all three initiatives are achieving significant outcomes in line with the objectives of their initiatives and client personal plans. These outcomes include:
- improved health and wellbeing resulting from improved ability to connect with services (including health services), improved personal coping and problem solving skills and increased confidence to manage their own lives and their mental health;
- reduction in the risks of mental illness through timely action on high risk behaviours and situations;
- reduction in hospital admissions, recurrence of severe mental illness and high use of health services, particularly hospitals and acute care services;
- improved ability to lead fulfilling lives.
Access by clients of Indigenous and Culturally and Linguistically Diverse (CALD) target groups are much lower than hoped. Many systemic and cultural barriers remain, which are largely outside the control of services.
Achievements of the mental health initiatives
PHaMs is seen as highly effective by clients and all stakeholder groups and it has made visible contributions to the service system for those with severe and persistent illness. Minor evolution in the program design and funding levels would substantially increase its effectiveness. More than 6,600 clients had been assisted by PHaMs by November 2009.
MHCB is also making a major contribution having integrated well with other services and providing high quality services for families and young people. MHCB services are generally provided based on sound evidence and contribute to the overall evidence base for mental health promotion, prevention and early intervention through evaluation work. These services have been effective in prevention and early intervention and constitute high value in terms of payback for investment. However the small size of the program means its reach is limited. More than 7,300 clients had been assisted by MHCB by November 2009.
MHR is providing essential services by carers who access it, but in many areas it is not reaching adequate numbers of clients who are carers for those who have a mental illness or in providing the spectrum of care required. It would benefit from simplification, changes to eligibility and changes to the service delivery system so more coherent approaches to care can be supported. A total of 19,000 clients had been assisted by MHR by November 2009.
Each Targeted Community Care Mental Health Initiative demonstrates the features of quality service and is making a substantial contribution to the service system in terms of increased access to services, improving service pathways and social inclusion despite only being recently established.
Service delivery models
The initiatives exhibit many synergies in objectives, approaches and models of care. Where services are within reach of each other regionally there is extensive cross referral between them. The extent of this depends on the capacity of the service, the other services that are available and the quality of the relationship between services.
All three initiatives are making a case to respond to family needs rather than just to individual client needs to serve mental health clients and carers more effectively and make a larger contribution to health promotion, prevention and early intervention.
Services exhibit high quality engagement and strong compliance by clients to agreed individual programs. This was confirmed through client interviews, case studies and reports by stakeholders (such as other services and family members).
The role of FaHCSIA's mental health initiatives in the mental health effort
Apart from PHaMs, the Targeted Community Care Initiatives (including rationale) are not well known to, or understood by, Australian state and territory governments or key stakeholders. The initiatives need to be communicated more coherently and cogently so that all stakeholders understand their rationale, what is being offered, and how the suite of initiatives supports the national mental health effort. To address these issues, stakeholders are calling for a FaHCSIA community mental health plan.
Policy direction and FaHCSIA's role under the national mental health plans<
FaHCSIA is seen as providing leadership in and impetus to psychosocial rehabilitation Non-government sector stakeholders welcomed FaHCSIA's involvement and regard it as consistent with and complementary to the large number of prevention, early intervention and targeted support programs already provided through other Australian Government and state and territory government programs.
Whole-of-government effort is being adversely affected by varying interpretations of the term 'community mental health'. Community mental health services manage a large spectrum of services for mental health clients from the traditional 'step up, step down services' and other individual clinical support to psychosocial approaches which improve the capacity of individuals affected by mental health problems to maximise social and economic participation. It is not always understood that FaHCSIA offers psychosocial services only.
FaHCSIA and the community service sector have much to contribute to the implementation and continuing policy and strategy development associated with the Fourth National Mental Health Plan:An agenda for collaborative government action in mental health 2009–2014. FaHCSIA should play anactive role in improving the understanding of the role of the community mental health sector in addressing social determinants of mental health and supporting its development.
Management of the mental health initiatives
Management of the mental health initiatives is regarded positively compared to programs funded by other agencies. The flexibility to meet needs is valued highly and there is a strong sense that FaHCSIA understands the business of mental health service delivery. However modifications to initiative management is required to increase efficiency and effectiveness. The MHR needs to be redesigned.
While the initiatives have benefited targeted groups, they have been implemented within a very complex service system. States and territories are concerned that the initiatives—because of insufficient consultation—are not being integrated optimally within the service system. These levels of government believe more consultation on the planning of service placement and more consultation with FaHCSIA on ongoing planning management issues needed. Key Non-Government Organisation (NGO) service providers have echoed the need to be involved in service planning effort because of their local and regional knowledge of the services and systems offered both by the community sector and government.
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6. Client outcomes from FaHCSIA's mental health initiatives
FaHCSIA's mental health initiatives have performed very well in achieving outcomes for clients of each program, particularly given how young the program is. This finding is supported by the extensive client, service and stakeholder interviews conducted for this report. The following outcomes demonstrate that the social and environmental risk factors for mental illness are being ameliorated and that access to services and improved pathways of care are providing the support clients are seeking.
The categories of outcomes service providers see being achieved for their clients are similar across all three mental health initiatives regardless of differences between target groups and types of service.
A set of high-level outcomes (Figure 1) were specified in the service provider questionnaire. The additional categories showing results for PHaMs only relate to the particular objectives and program guidelines for PHaMs. The high-level outcomes include:
- better health and wellbeing;
- improved connection to needed services and support for better pathways of support and care;
- increased confidence in client ability to improve;
- reduced social isolation and increased connection to community services and activities;
- improved family relationships;
- better coping skills and increased living functionality;
- access to other needed services such as long term and safe housing, employment and income support;
- participation in community activities including education and employment.
The following section reports on these outcomes, firstly from the perspective of service providers and secondly from the client perspective for each initiative. The outcomes service providers see being achieved for their clients are similar across all three mental health initiatives.
Outcomes for clients of Personal Helpers and Mentors Service
Figure 1: Outcomes for Personal Helpers and Mentors Services clients
Client views were derived from interviews, telephone discussions and focus groups with more than 150 clients during service visits. Overall PHaMs clients believed this service was responsive, well designed, highly effective and empowering. The only consistent negative comments from clients were that they would like more time with their worker and that staff turnover affected their recovery as they had to get use to a new person.
Service model, client engagement and compliance
The recovery approach is highly effective in engaging clients, generating their trust and empowering them to achieve their personal goals.
From the client's perspective the approach is respectful and empowering. Most clients said it took about six to eight weeks to trust the service because of previous unpleasant experiences with mental health services. For the first time in dealing with mental health problems clients believed their views were not only heard but acted on.
Clients found the services were not as demeaning as were other medical services. This motivated them to approach services with commitment and confidence.
Some client views:
Being listened to was a key factor for me in deciding to trust the service and in summoning the courage to try something new.
I know myself best and I like being in charge of my own progress. I find it scary and demeaning when doctors and others take over. I lose confidence in myself and just do what I am told.
Clients appreciated being involved in discussions with other services contributing to their recovery. They liked how goal setting and planning helped focus their effort.
The development of plans for progress gave clients a focus and they appreciated the capacity to set achievable goals and then to review and expand their plans as their confidence and capacity increased. They also appreciated the development of plans for emergency situations which reduced their uncertainty and anxiety about sudden relapses and the impacts on their families.
If I get sick my kids know what to do, who to contact and where to go. My mail will be collected and my electricity won't be cut off.
My dog, my best friend, will be looked after.
Clients also appreciated being able to work at their own pace because it made the process of recovery less intimidating.
For many clients, getting out of the house, taking public transport and even shopping are very challenging activities. The tailoring of plans and the flexibility to adapt them progressively allows clients to proceed at their own pace. Clients found this less daunting at the outset and it allowed them to build confidence as they progress. They feel less pressured by what they saw as artificial milestones and deadlines. Some comments reflecting these sentiments were:
It took a long time to leave my house as I hadn't been out much for at least 10 years. I used to collect my mail at night and rush down to the supermarket only when I had to and when it was quiet. At first my worker used to visit me at home. Once I ventured out with my worker I think I improved a lot more quickly. Now I go out to meet my worker at a coffee shop, use the buses and am doing some volunteer work. My worker and I are discussing a TAFE course and I am feeling quite excited about it.
My worker started me cycling to get to the gardening group. I was very reluctant but he came with me, then started meeting me half way. Now I cycle everywhere. I also feel better because of the exercise.
No unreasonable time limits.
The program recognises that it can take some time for recovery. It is such a relief to find something that is not limited to six sessions or a five minute consultation. That just doesn't work.
Involvement of peer support workers.
Clients expressed appreciation about the involvement of peer support workers:
It gives me a lot of inspiration—perhaps I will be able work again one day. David really understands what I am going through.
I recently completed a file creation project on behalf of a stakeholder in Washington. As he had a very limited understanding of records management, I made sure I explained things in an uncomplicated way and kept him up to date with the project via email. As a result of our correspondence, this stakeholder developed an understanding of file creation processes which he then applied to his other projects.
Clients have a sound understanding that while they do not have to progress at a pace beyond their capacity, there is an expectation that they will comply with their recovery plans to the best of their ability and that they will need to exit the program when they are well enough. Clients appreciate the flexibility of approach.
Clients report being able to do a range of things they could not do previously, such as establishing daily routines, taking public transport, cooking their own meals, conversing with other clients and looking after their room or house.
Learning to recognise symptoms of problems before total relapse of a condition, to learn and apply management strategies like returning to a General Practitioner (GP) or psychiatrist, or applying what had been learned about self management was highly valued.
I used to be hospitalised two to three times a year for depression and suicide attempts and I haven't been in hospital for about 18 months now. (Client of two years about to exit PHaMs).
Access to services was improved.
Clients really appreciated outreach services because many expressed feeling intimidated by institutional settings. The ability to meet their counsellor in a familiar setting and on their own terms was found to be a much more positive experience. Clients found they established trust in the process more quickly. For many it also avoided difficulties in accessing transport and coping with unfamiliar settings, especially at the outset of their program. The following comments illustrate these points:
It makes a big difference not to have to sit facing someone across a desk. here is always a sense they are judging you.
I feel as if my support worker and I are having a conversation between equals. She meets me where I feel comfortable and respects my views.
Getting to the service is too hard so I appreciate that the worker meets me where it is convenient and I don't have that stress.
Clients also reported that they now realised the value of being re-engaged with the health system. They also realised that the health system plays an important role even if they found it confronting, uncomfortable or disagreed with treatment. Clients especially appreciated the support of their worker when they wanted a medication review, or needed someone to help them express what they wanted.
The fact that my worker came with me to the psychiatrist made all the difference to my confidence.
Clients were also connected to a range of services they were previously not using, for example, Centrelink, housing, public transport, libraries and support groups.
Social isolation was reduced. For many clients participation in interest groups—such as gardening, art, drama and music—gave them a sense of connection with people who had similar interests, could understand their perspectives and helped reduce their sense of isolation. Interest groups were an important first step for many clients in developing skills, building on their own talents, and restoring skills in working with others.
Overall clients reported improved confidence, more knowledge about their condition and more connectedness with family members, with a range of services such as Centrelink, housing, employment, and social and community inclusion. They reported increased ability to manage their lives, a sense of achievement and hope. Overall clients reported more resilience, better problem solving skills, healthier lifestyles, improved quality of life, improved security and improved family and community relationships.
The carers and relatives of PHaMs clients also reported significant progress, including better understanding of mental health conditions, how to pick up signs of deterioration, how to live and relate more effectively to these signs and understand recovery principles and processes. They also reported improved health and wellbeing. The recovery approach gave them more hope for improvement and confidence in the future.
Outcomes for clients of Mental Health Community Based Services
Service perspectives on client outcomes of MHCB are represented in Figure 2.
Figure 2: Outcomes for clients in Mental Health Community Based services
Client perspectives on benefits of MHCB
Client perspectives were derived by speaking with more 80 clients in focus groups and in telephone interviews, and through examining case studies and examples given by service providers. Much of the information was able to be triangulated with views of other family members and schools.
The main themes emerging through client responses were as follows:
Prevention: increased understanding of mental health/mental illness and its triggers, preventativestrategies and the importance of seeking help in a timely way.
Early intervention: timely interventions which halt escalation of problems. These have been achievedfor children, individuals and families who are at risk of mental illness, because of a range of personal and societal risk factors. Strategies used for early intervention include:
- increasing family resilience and development of skills in coping with the impact on the family of a person with a mental illness;
- connecting people to needed services (such as Centrelink) and helping them resolve outstanding matters such as taxation and debt reduction;
- reducing social isolation by linking clients to peer support networks.
The following examples illustrate the benefits of MHCB as expressed by clients. These examples illustrate the range and complexity of MHCB cases and outcomes:
- Children at risk of suspension because of truancy or bullying have been counselled and supported in developing strategies to cope. Comments from the provider ("Shine"), school principal and school counsellors perspective were:
Shine developed a group program on bullying which is essentially seen as a leadership program by the participants. They are learning new skills and the problems at school seem to have dissipated. They are also happier at school.
School principal: Shine's assistance in supporting the school in preventing an escalation of problems was invaluable. As well the children in the group sessions are responding well and are reporting new understanding and skills.
School counsellor: I have developed my skills by working as a joint facilitator with the Shine team and it was wonderful to have this community support for our school. It is wonderful to know they are there as I cannot meet all the needs presenting in the school. As outsiders the children gave them a high level of respect.
- Families have learned strategies for dealing with difficulties posed by child anxiety and the inability to deal with having a parent with a mental illness. The following comments from the family perspective illustrate the positive outcomes:
Grandparent: Through the support of the service I have learned how to respond to my grandson's anxiety about his mother and his grief from losing his great grandmother. His therapy with the service has helped him deal productively with his grief, he is coping better with school and he has more understanding of his mother's severe mental illness and strategies to cope with this.
Mother: I have had my children returned to me and we are now coping better. My daughters are getting over the trauma of being taken into care and the worker sees us all individually and together. We have negotiated better ways to relate to each other. The girls know they can text or phone the worker at any time. This service has been like a guardian angel.
Interviews with clients and stakeholders, as well as results from evaluation reports, demonstrate that at a minimum the following outcomes are being achieved.
- Increase in mental health literacy by family members, schools and community members. This enables detection of possible problems and help seeking at an early stage so illness can be prevented. Many services have education programs in a variety community setting such as schools, workplaces and services through which people learn about emerging problems.
- Specific outcomes reported by clients and stakeholders include:
- improving the ability of parents and schools to identify children with problems either when children are too quiet or deal with obvious problems such as anxiety, aggression and bullying, assisting with post natal depression, alerting people to the need to seek medical help;
- supporting children to deal with grief and loss, anxiety and relationship and caring issues where their parents have a mental illness.
- More effective strategies by individual children and families. This has enabled children and families to develop ways to deal with conflict, develop the skills needed to engender cooperation by family members and improve coping skills in dealing with everyday problems (resulting in a more orderly life). It has also improved access to services.
- Early intervention through small group and individual case management. This is especially the case in improving problematic behaviour before it escalates into major risks. Early intervention includes working with families to:
- reduce the likelihood of children being taken into child protection;
- improve relationships and parenting skills, which in turn reduces the risk of a child being taken into care.
- Better access to services. Clients reported they were helped to access services that they did not even know existed. They also received support with housing, social welfare and other needs:
The worker comes to our home and works with the whole family, as well as my daughter.
- Development of analytical and coping skills through therapeutic interventions with individuals:
My daughter tells me that when she starts feeling angry, instead of allowing it to get worse she can now recognise that she is thinking "red thoughts" and decides to change them into "green" thoughts. She is now getting on better with the family and at school because we can all talk about the things which upset her.
- Family relationship skills by parents. This enabled parents to develop insights into family dynamics:
I didn't realise that I was actually escalating my son's problems. Now I have strategies for recognising the triggers and dealing better with my anger and anxiety so I don't take it out on him.
- Reducing risk factors for young people. This involved working with young people to address risk factors arising from homelessness or the risk of homelessness:
Teenager: I know I can ring at any time. I was living on the street when I heard that this service helped young people. They found me somewhere to stay, even though it isn't a permanent home. I know they are trying to find me a place and they are helping me get into a TAFE course and they are also giving me more skills to find a job.
- Making plans for clients regarding change and improvement and contingency to manage risk. This involved helping clients developing goals and plans. Clients indicated they appreciated this because it gave them a sense of control over their lives. They felt empowered and involved in solving their own situations:
My former husband, who lives in another city, has a mental illness and my children feared being alone if they were there on holidays and he had a relapse. The worker developed an emergency plan with them including emergency contacts so they knew what to do, so they felt confident to go and see him and his girlfriend. They have had to use the plan and it worked, so they feel in control of the situation now.
- Developing greater confidence with clients and developing their skill in social interactions and in building relationships and reducing social isolation:
Teenager: The worker has taken me to a couple of groups (sporting and social) and I have met new people, which is good. Also they don't know about me so I don't feel ashamed that I have been in trouble.
- Providing community education:
I recognised that I had symptoms of depression because of the seminar. I went to see the doctor and I am also getting counselling from the service. I didn't want to use counselling through Medicare because I can't afford the co-payment and I knew that I might need other family members to do some counselling with me' so I went back to the service and had counselling there. My family became involved as well.
- Service access improved through outreach:
Teenager on outreach: I would never be able to have the fares to see a worker as often as I need to, I feel as if my views and needs are respected when the worker asks me where I would like to meet, and encourages me to phone him when I can't cope.
My worker comes to the school so I can just stay on after school rather than having to find my own way to an appointment. I can now understand why I am so angry and am learning to cope with school better now.
Outcomes for clients of Mental Health Respite
Service perspectives on client outcomes are illustrated in Figure 3.
Figure 3: Outcomes for clients in Mental Health Respite services
Client perspectives on benefits of MHR
Client perspectives were derived from interviews with more than 70 clients—face-to-face, by telephone and in small groups.
Clients were grateful for any form of support so there is positive bias in the comments included in this section of the report. Some clients, however, noted that they would like more regular support. The following examples of benefits, as expressed by clients, illustrate the range and complexity of MHR cases and outcomes:
- access to services that were user friendly, responsive, respectful and empowering:
I kept on being told that services had waiting lists and I had to make do with bits and pieces of service. This is the first service I have had which has tried to find out my biggest needs and act on them first.
The fact that the service is there and I know I can call them has given me real peace of mind.
- reduction of stress creating the ability to continue caring for a client with a mental illness:
I was at my wits end. My son who has autism kept escaping and walking down the middle of the highway. I asked for support to repair the fence. I now have a new high fence and I don't have to watch him every minute. My neighbours are happy too. They have told me that they are less disturbed by the constant noise he makes now.
- more informed about mental health conditions and development of skills in coping with the impact of a person with a mental illness on the family:
When I attended the course on recovery I gained a lot of hope and a sense that something could be done to help my parents, my brother and sister. My sister and I are working through the materials and taking steps ourselves. We know where to advise our family to go now. (Young woman aged 23)
Carers got in touch with me when my wife was hospitalised for eight weeks with depression. When my wife came home they came and cooked meals for the first couple of nights. Now they are teaching me to cook and I know enough to cook enough meals for half a week. I am very proud to be learning something new. It is a wonderful service. (Respondent aged 70)
The camp was really good. We were given information about mental illness and how to recognise signs of a relapse, stress management and time for relaxation too. I felt pampered and the meals were lovely. I was able to take my wife and she had activities during the morning so she was happy too. I feel much better able to cope now.
- assistance with getting the household in order (client not on top of household affairs because of lack of time and/or emotional and logistical ability):
I was threatened with eviction as the house and yard was full of my husband and son's stuff. They both suffer from a mental illness. The service helped us clean it up. They brought a skip and took a lot of it away, and helped with a clean up. It was hard but we still have a roof over our head.
- assistance in connecting to needed services, such as Centrelink, and helping with resolve outstanding matters such as taxation and debt reduction:
I just couldn't keep up with paying bills and they cut my electricity off. I was too busy with my son to get away to do those things. The service helped me get it in order and put plans in place so it doesn't happen again.
- ability to gain the time needed for important personal matter such as attending to the needs of siblings, attending parent–teacher meetings or taking family members to appointments:
Everything changed when my son was struck down with mental illness. It is hard on all of us and my other kids miss out on my attention. When my son comes to the fishing group I try to do all the things I can't get out to do like take them to the doctor, buy their school supplies or just have time to pay bills.
- reduced social isolation by linking clients to peer support networks:
Coming to this group has helped me keep myself sane. It is my time out. I've learned a lot too. (carer)
- ability (NRDF clients) to attend extra curricular activities, such as art and gardening,— these client spoke of their experiences in positive terms, noting that they were building confidence, for example, in riding a bike to the group, learning new things and as part of that realising they had hidden skills:
I have sold a few of my paintings before the exhibition, which I am organising.
I hope to get back to work one day.
I have been asked to organise a film club with the peer support worker.
I have discovered that I really love fishing.
Yoga is wonderful. It has helped me deal with my anxiety. (mental health clients of NRDF) - ability to continue to work or study:
I can continue with part-time work because a carer comes to be with my daughter an hour a day so my husband—who looks after her when I am at work—can get to his shift work on time.
- ability to reconnect with family:
We have been coping with our two daughters with mental illness on our own for 40 years and it has limited what we can do as a family. Recently my wife was assisted to visit her sister interstate whom she hasn't seen for over 20 years. That has meant so much to her. It is wonderful that someone has finally recognised the effort it takes and the personal costs [to take care of someone with a mental illness].
Challenges in serving the needs of special target groups
Interviews with service providers and survey questions specifically explored issues related to meeting the needs of Indigenous and CALD groups.
Indigenous Australians
The needs of Indigenous Australians are many and complex. Issues facing Indigenous communities include high levels of unemployment, social breakdown, alcohol and other drug abuse, crime, welfare dependency, poverty and high rates of mortality. Cultural and language differences, remoteness, unique histories and particular emotional needs mean that providing equal mental health services to address the needs created by these issues frequently require distinct approaches that recognise the cultural and spiritual understanding of Indigenous communities.
Culturally and Linguistically Diverse groups
People from CALD backgrounds face barriers to accessing and receiving appropriate (culturally sensitive) mental health services. Issues include social isolation, marginalisation and discrimination, as well as access to services.
Humanitarian entrants are included in CALD groups and these entrants require specific approaches to addressing mental health. Many refugees have fled persecution or torture. They often suffer trauma as a result of war and conflict in their countries of origin or while fleeing those countries. Mental health problems commonly experienced include depression, post traumatic stress disorder and persistent thoughts of suicide. To address these issues, CALD groups require mental health services that are culturally and linguistically appropriate.
Meeting the needs of Indigenous Australians
Most services across all initiatives reported great difficulty in attracting Indigenous clients compared with some other communities. Services providers indicated they do not feel culturally competent in designing for and delivering services to this group. Some services stated they did not attempt to serve Indigenous Australians because of their limited understanding on how to do so.
Most services have made serious attempts to attract and serve this client group where they have had a significant population profile in the service catchment area. Common approaches include:
- building networks with Indigenous organisations and communities, such as Land Councils, Aboriginal Medical Services and Indigenous training organisations;
- using opportunities through activities and events such as National Aborigines and Islanders Day Observance Committee week celebrations, dinner, sports days, awards and service stalls as well as through local community and other service providers;
- employing Indigenous staff and providing Indigenous trainee positions;
- undertaking cultural awareness training for other staff in a service.
The main difficulties experienced have been in getting engagement and trust from Indigenous clients and their families and communities as well as referrals from Indigenous service agencies:
Time taken for the service to be known and trusted by Aboriginal communities, families and elders through successful and sensitive work with individuals, time taken to recruit aboriginal staff, complex co-morbidity issues.
The small Aboriginal community in the site has several Aboriginal health workers who attend to education, and a variety of health needs. The community does not wish to be referred to any other services or to self refer even though statistics show that there are a number of people who have mental health and drug and alcohol concerns. There has been resistance even to some health workers being appointed due to the fact that they are not from a "family" acceptable to the community.
Understanding their specific cultural beliefs/needs and family structure. Working with the families on a holistic level to ensure appropriate services are provided that sit comfortably with the client and their family.
Stigma within the Indigenous community with people being unwilling to identify as having a mental illness. Preferencefor mental health issues to be dealt with within the Indigenous community.
Lack of availability of training for staff in how to work with people from Indigenous backgrounds.
Our Aboriginal participants have tended to engage during crises, but at other times not participated consistently unless the support has been very driven by the PHaMs worker. In some case these clients have not wanted Aboriginal workers. Sometimes we may not be sufficiently aware of the cultural diversity with this group of clients.
We have received referrals but usually the person does not want to follow through, rather, wanting to access Indigenous services.
However, many services are succeeding in delivering services to Indigenous people. Strategies include: employing Indigenous staff; building closer relationships with Indigenous community organisations (for example, drug and alcohol); and ensuring that service staff undertake appropriate training, including cultural awareness and developing cultural competencies.
Comments from service providers working in services that are making progress toward developing cultural competency include:
Actively sought to employ Aboriginal staff as essential element to the service, built the reputation of the service and slowly gained the trust and respect of local aboriginal organisations, groups and elders. Close liaison with Aboriginal support services, individualised and highly flexible approach to supporting aboriginal participants, improving staff skills in identifying and meeting the needs of Aboriginal participants through cultural competency training.
The service has been collaborating with the mental health teams, including a Mental Health Aboriginal Liaison Officer for a Drug and Alcohol Centre which is just outside the site, and the site has been successful in encouraging and receiving referrals from three participants who identify as Aboriginal.
PHaMs works in collaboration with such services to link Indigenous participants with extended family and Elders to reconnect participants with key cultural and emotional supports. Refresh and further develop knowledge in working with multicultural communities through ongoing training, sharing of strategies and resources, through interagency participant co-case management meetings.
Indigenous specific services such as Danila Dilba are part of an Aboriginal community-controlled health service and the links between the two are mutually beneficial and a source of referrals for both.
Challenges in meeting needs of Indigenous Australians
Assertive but culturally sensitive strategies must be used to engage Indigenous Australians. Successful services had a history of providing services to this group and had developed sensitivity to cultural issues, and well established engagement and service strategies. They also used a family-based approach to serve the needs of Indigenous families and communities as part of supporting individuals, by cross subsidising mental health services with other funded services.
Many service providers presumed that simply having an Indigenous member on staff would improve their ability to serve needs. A number of Indigenous staff advised that they had succeeded in connecting with Indigenous community members but a number of issues needed to be considered. These service providers can face an enormous burden of responsibility for the outcomes of Indigenous people, have disproportionately high workloads and may not feel skilled enough to face all the challenges presented. Depending on their role they need to feel part of the larger team and have the opportunity to service clients other than Indigenous ones. Where only one Indigenous worker takes responsibility for servicing Indigenous clients, it poses management issues which are not always obvious. The views of one Indigenous worker on a team may, for example, be given disproportionate weight and the service may be ill equipped to provide critical evaluation and advice. Additional strategies for supervision and quality assurance may also be needed.
There is further need to build understanding and relationships over time. Services that have succeeded in doing so have been involved with communities over some years.
Meeting the needs of CALD groups
A number of services have developed successful strategies for engaging CALD communities but many have encountered enormous barriers in attracting these types of clients. Some catchment areas have few CALD communities or highly diverse ones, making it difficult to engage staff who can offer services while meeting the needs of cultural groups sensitively and comprehensively.
Language barriers and difficulty in accessing interpreter services—both because of availability in a catchment area and the cost of the services—were the most common difficulties experienced by service providers working with CALD clients. The lack of consistency of interpreters poses a barrier to quality service. As well, staff are concerned that lack of interpreter experience specifically in the mental health field may lead to poor integrity of communication.
Concepts of mental illness and stigma associated with mental illness in many communities form other barriers which require skilled staff and tailored strategies. Services that have been funded to provide specific support to CALD groups have developed approaches which are highly suited to the communities served.
Comments from service providers follow:
Many of the newly arrived communities, for example, Africans, have a different concept of time management. Many are either working or going to learn English at TAFE (this is why we have targeted TAFE Queensland to work in collaboration with). Childcare is always a big challenge. Stigma around mental health in most CALD 7 communities is very high and it is difficult to break down the barrier, particularly if there are strong religious beliefs about mental health within those communities. It continues to be a challenge to find the right worker within those communities who has a mental health background and strong connections and influence within those communities and is able to make a difference.
Service providers advise that they have difficulty in getting enough referrals and that migrant services seem reluctant to refer to them. A common theme emerging from interviews and survey responses related to committing the time necessary to continue collaborating and forming partnerships with appropriate organisations and to keeping information in appropriate form available to potential clients for long enough to give them an opportunity to observe and check out the service and gain the degree of trust necessary for them to engage with the service.
7 - Culturally And Linguistically Diverse
Providing services for CALD groups is resource intensive and challenging and not all service providers believe they have the capacity to do so:
The turnover for translated materials is very slow. The activities we organise are often started before we can get the information back translated or find someone to translate. Finding the groups to access or activities they would be interested. We are not sure that expos are that successful.
There are a large number of different ethnic groups in the LPA but there are relatively few individuals within each group who tend to be spread over a large geography. Insufficient time for our respite coordinator to get out to market to these groups.
Some of the general challenges include issues such as language barriers, cultural understanding, beliefs and traditions and family trust. Our biggest challenge is meeting the CALD families' needs and expectations.
However there is evidence that if sectors collaborate then effective strategies can be developed. The Connecting Communities Program (Brisbane South Division of General Practice), for example, has a number of innovative strategies for Indigenous and CALD communities. They have built the capacity of a number of communities covering Indigenous and Asian people in parenting, and have worked to educate and de-stigmatise mental health, through delivering culturally appropriate mental health first aid programs for these groups. The results described below demonstrate the effectiveness of this approach.
Statistics from the Mental Health First Aid (MHFA) through the Respite Initiative, connecting communities program, Brisbane South Division of General Practice
It has delivered training to 400 members of the community in Mental Health First Aid.
15 per cent of MHFA participants identified as being from Aboriginal or Torres Strait Islander descent.
17 per cent of MHFA participants speak a language other than English at home.
46 per cent of people who have participated in a MHFA course had experienced a mental health issue sometime during their life.
68 per cent of people who have participated in a MHFA course have a family member who had experienced a mental health issue sometime during their life.
90 per cent of people who have participated in a MHFA course had contact with someone with a mental illness in the past six months but most felt only moderately confident in helping someone with a mental illness.
Analysis of pre and post data following the MHFA course show a significant increase in participant's confidence in dealing with a mental illness.
Participants following MHFA courses reported less stigma towards people suffering a mental illness, and also were more comfortable with interacting socially or working with someone with a mental illness. Within six months of completing the training many participants had encountered someone with a mental illness and felt able to assist them appropriately as a result of training.
The team also provides a mentoring network/respite program called Chain Reaction, which aims to support socially isolated people with a mental illness living in the community. Chain Reaction aims to collaborate with people in their journey of recovery and to provide brief respite for their families and carers. This network will match the most disadvantaged and isolated people in the community with a 'friend' who will take time on a regular basis to go on a regular outing.
Conclusions on working with CALD communities
Meeting the needs of CALD communities remains a significant challenge for most mental health services. CALD communities require similar approaches to Indigenous communities—taking family needs into account, understanding the issues and sensitivities pertaining to culture group, communicating in a language other than English, and developing strategies which may need specific development. Servicing this group requires more time and resources than does servicing English speaking groups.
However, the challenges are not insurmountable. Across the FaHCSIA Mental Health Initiatives interesting and effective models have been developed. These need to be disseminated across the sector. There is also a need to work with agencies such as Multicultural Australia to develop service strategies which will better address the needs of key groups, including through mainstream services and developing partnerships with relevant multicultural agencies. These services and partnerships need to be resourced.
Conclusions on outcomes for clients
The consultancy team is assured that clients who have accessed services under all three initiatives are achieving significant outcomes in line with the objectives of the program and client personal plans.
Achievements for Indigenous and CALD groups have been less notable. Clients who have used services report sound outcomes similar to those reported for other client groups. However although most service providers have made substantial effort to engage Indigenous and CALD groups their capacity to attract these groups into mainstream services remains challenging Meeting the needs of these groups is hampered by the complex social and economic challenges these groups face and the requirements these place on staff. These challenges include staff feeling they lack cultural competence; restrictions posed by services and funding models, and the attitude of groups designed to serve these organisations.
Building the capacity will require approaches such as: developing more appropriate models of care (such as family oriented approaches) and allocating adequate resources for these; assertively building the Indigenous and CALD workforce in mental health; combining targeted Indigenous and CALD effort with mainstream services, partnering with Indigenous and CALD organisations in delivering service; and building the capacity of those organisations to better use mainstream capacity to improve access to Indigenous and CALD groups.
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7. Service outcomes: effectiveness of services against principles of good service practice
Sound principles form the basis of the consistent framework needed to prioritise, plan and assess appropriate service delivery. PHaMs, for example, has a set of principles which support recovery services. MHCB and MHR have similar principles which support client centred care services. The principles applied here are generic, encompass the ones incorporated formally and explicitly or implicitly in each initiative and provide a consistent and generic reference point for assessment of all services for the purposes of this evaluation. They are not meant to undermine existing frameworks and philosophies such as the 'recovery principles'.
Responsive, relevant, user friendly services
The goals of each initiative are expressed differently but the underlying theme is that of responsiveness of services to meet client need whatever the target group and whatever the context. Responsiveness incorporates respect for clients and support to help them develop their own goals and plans as well as build on their own strengths.
The causes of mental health problems are multifactorial and encompass social and economic determinants of health as well as predisposing genetic disposition to problems. For these reasons, clients may present themselves to service providers with a range of interrelated problems. Therefore services must be client focused and organised so they respond flexibly to client needs not so client have to fit into the existing service system.
While each initiative has focused on the needs of a particular group within each service type clients have had diverse needs. In PHaMs and MHCB particularly, clients have worked with services to develop plans, adhered to them, and persisted and reoriented goals when there was a problem in implementing them. Clients were able to relate their progress and achievements and the processes of change.
Outcomes achieved by clients can be considered a key indicator for relevance and responsiveness of services. Overall clients reported improved confidence, more knowledge about their condition, better connected to family members, and better connected to a range of services such as Centrelink, housing and employment. They reported positive gains in social and community inclusion, including increased ability to manage their lives, a sense of achievement and increased hope. Overall they reported more resilience, enhanced problem solving skills, healthier lifestyles, improved quality of life, improved security and improved family and community relationships.
The recovery principles used by PHaMs services were uniformly praised by clients and service providers as being effective and empowering. Clients appreciated being able to work at their own pace and not feeling pressured to achieve results in a limited time frame or specified number of sessions.
The MHCB services were also cited by clients and many other stakeholders as being highly responsive and highly effective. Interventions were shorter term with plans and progress depending on client capacity and the complexity of their situation.
Clients of MHR services were less able to report similar experiences in processes of care but carers reported that they had had their individual needs assessed, reduced their stress, developed more knowledge about mental illness, learned new skills and were better able to cope with the demands of caring for someone with a mental illness. The clients with mental illness reported enjoying outings and group activities, developing new skills and also developing networks.
All services have performed well against this principle, as determined by the assessment of outcomes for clients of each initiative. Refer to reports of each initiative in Part C.
Thorough client needs assessment and effective case management
Client (and family) needs assessment is an intervention in itself and should be undertaken sensitively with regard to the provision not only for information and insight for services but also for the client. It should be comprehensive and encompass an examination of the range of risk factors and sources of strength for clients. The assessment should therefore cover a range of issues such as housing, financial security, health, family functioning, social connectedness, functional impairment and client abilities and strengths. Where other services need to cooperate as part of a client plan, there is much benefit in using common assessment tools.
Services understand the need for sound and professionally conducted needs assessments. Various approaches are used across the three initiatives.
PHaMs uses the EST as an assessment tool with a primary focus on eligibility. Opinion is divided about its utility. Many services supplement the EST with other tools to gain a more definitive understanding of needs and to measure client progress towards outcomes. In services visited by the authors supplementation included care coordination or more intensive care plans between services and supporting client recovery plans. While the way EST was supplemented varied between services, the overall principles and approaches applied were similar.
Projects funded under the MHCB use a range of assessment tools aligned to the particular service or situation being addressed. For example, services supporting children of parents with a mental illness that use Children of Parents with a Mental Illness (COPMI) approaches rely on a tool from
SHINE (service provider) which is implementing the 'Friends for Life' program. Many services integrate many methods depending on the need. One service in Melbourne has developed a tool to assist initial rapid assessment of need so clients are directed to an appropriate starting point for a suite of services.
MHR also has a needs assessment tool but clients frequently need to undergo more than one assessment because of the difference in approach between brokerage and other services. This means client have to tell their stories more than once, which is time consuming. This distresses some clients and dissuades some from continuing with MHR.
Service providers find needs assessment and client case management approaches an area in need of development. Difficulties arise from varying philosophies and protocols for care. These are affected by funding requirements, service preferences, legal and other requirements of different sectors. For example, services focusing on individual disease diagnosis and treatment oriented concerns, have different priorities than do PHaMs, which focuses on client recovery. The following quote from a PHaMs provider illustrates this type of concern:
Sometimes GPs, psychologists and psychiatrists, seem to have little knowledge of individual psychosocial rehabilitation. They are unaware of evidence that demonstrates the enormous benefits for clients and the evidence that these kinds of services can provide an average reduction of more than 50 per cent in cost of care due to reduced hospitalisation. Studies have shown that clients with a diagnosis of schizophrenia may have a higher potential for recovery than previously thought (R Burton Psychosocial Rehabilitation Services in Community Support Systems Psychiatric Services April 1999 vol 50 no 4). In some cases they may be unaware of best practices in regard to self-management and chemical treatments. In one case a GP would not provide his care plan to the client or to PHaMs!
Professions and services across the health sector need to understand the role of others who provide services. They must also provide input into and agree on a client plan as well as comply with management processes. This is a fundamental prerequisite for effective case management and quality client support.
System change cannot be achieved by efforts at service level alone although it is possible to enhance systems locally this way. Improvement involves input from Australian Government and state and territory government levels.
Holistic services—providing a wide range of assistance to clients
The interacting factors which lead clients to mental health services are often complex and interrelated. The level of need depends on the level of personal and environmental disadvantage. Usually a range of issues need to be addressed and a range of services may be required in response.
Usually multiple problems need to be addressed and issues identified and prioritised during needs assessment. This usually results in jointly developed client plans. Holistic services are able to respond by combining a range of service types such as education and skill development, counselling, therapy, advocacy with other services, liaison and/or referrals, as well as practical assistance through brokerage and other means. Social and recreational services are also important.
Yet few services—except those that are part of larger parent bodies—have the range of skills and services to respond. There is a need for initiatives to work collaboratively with other service types such as health, housing, employment and criminal justice to ensure seamless support and assistance. Most service providers depend on developing sound service relationships and collaborative practices with a range of services to access the skills and resources required. In any case many services combine centre based and outreach strategies to reduce the inconvenience to clients, overcome their fear of entering new facilities, and avoid transport problems (especially families and the functionally impaired). A range of services may participate in those approaches if they share the same service philosophy.
A one-stop shop approach to service provision is often advocated. The FaHCSIA mental health initiatives interpret this as a 'no wrong door' approach. While it might be convenient for clients to have one agency offer a range of services, which could result in greater take up and compliance, there are disadvantages to the one-stop shop approach. Some stakeholders, particularly those providing funds, are concerned that client capture could result and that where separate services are involved client dependency and unnecessary service use may result. However, based on client interviews, this concern seemed to be misplaced for this program. Across all initiatives clients indicated that their plans were oriented to achieving independence and building coping skills. All services interviewed describe strategies (individual client plans, reviews of progress and exit strategies) to ensure that clients do not become dependent on only one service.
All three FaHCSIA Mental Health Initiatives have demonstrated the capacity to work holistically with clients and most do so within the constraints of individual and regional service capacity. Some have developed highly sophisticated approaches within and across services to provide such support. Services quote a 'no wrong door' philosophy so that enquiries to a service may result in an assessment of needs and a range of actions. If the service cannot assist appropriately, clients are helped to find one that can. Some services were explicit about and stayed true to their niche, referring clients they could not help to other services. This is particularly true of MHR.
One issue which affected the range and quality of services with the FaHCSIA Targeted Mental Health Initiatives was the requirement to offer non-clinical services. This requirement is interpreted in different ways across the mental health system. Some, for example, believe it means that counselling is not offered because that is perceived as a health system responsibility. These services employ certificate-based staff only and the services tend to operate quite differently, offering more limited service opportunities internally. Clients often have to join waiting lists of other service organisations. Others employ staff with counselling and therapeutic skills (for example, social workers and psychologists), and many of these staff supplement their income though the Better Mental Health Access Program:
Danila Dilba, which is an Aboriginal Community Controlled health services and which has a MHCB attached, has psychologists and social workers who also work under the Medicare fee for service provisions. All work of the MHCB is integrated with the general practice services, including utilising the central client record keeping system.
Service providers interviewed noted the high need for counselling and indicated they would like to have more capacity to provide this service. The need to refer to other services often resulted in long waiting times and reduced rate progress by clients.
A number of services illustrated refer complex clients to specialist services which can better address complex and intractable situations. This includes, for example, referring clients with severe difficulties requiring specialist psychological therapies to the mental health service for personality disorders.
Once a client is deemed to be eligible for a service they undergo a thorough assessment follows. All initiatives follow this pattern to some degree although the approach is refined for PHaMs and MHCB and includes planned responses. The MHR initiative makes it clear that sound needs assessment are completed but it is not as evident that planned responses follow. There are many exceptions to this where services base their work on the cycle of service models developed by Carers New South Wales and similar approaches.
PHaMs and MHR noted that in assessing client needs the involvement of family members and other services to the family was an essential. Their work with clients was limited by having to restrict their assessment and support to individual clients when the family also had problems which needed to be addressed for their own and the client's wellbeing. Individual client models also hampered work with Indigenous and CALD groups who regard a family-based approach as culturally appropriate. MHCB illustrates the effectiveness of family-based approaches. While these approaches have implications for resourcing and service organisation it would be worth considering giving services the opportunity to incorporate them into their service model.
Effective networking, collaboration and practical working links with services
Networking and collaboration with health services and a wide range of mainstream services—such as alcohol and drug agencies, income support, housing services, corrections services and a range of community based services—are required to address the full range of needs and service delivery options for individuals, carers and families.
At face value collaborative practice enables more extensive service. However, a number of challenges arise for effective responses through networking and collaboration. Services must, for example, have an up-to-date understanding of their roles, what they can offer, their operating philosophies and constraints such as policy and service boundaries and funding. They must also ensure that they understand the potential for and mutual benefit working together as well as the benefit of this approach for clients.
Services should also understand and respond in an informed way to the type of collaboration required to meet client needs. Figure 4 represents a range of service relationships with intensity of relationship increasing from left to right.
Figure 4: Different types of partnering relationships and purposes
Networking extends from relatively informal connection between services and individual case workers to share ideas and resources to more formal connections which support client service. Networking is the least resource intensive way to support referral of clients and client advocacy.
For more serious cooperation and collaboration, strategies and protocols are required to develop and maintain agreement on how to work together including relative responsibilities. These support the establishment of joint work which results in effective and reliable pathways of care. The intensity of the strategy depends on the level and cooperation required to meet client needs and especially where services have developed interdependent roles. Such work must be supported by clear understanding of roles, case administration protocols, individual responsibilities, ethical guidelines and data management. Collaborative work is resource intensive and both funders and services needs to resource the planning and administration of joint projects.
All services report a range of collaborative relationships, as illustrated in Figure 5, but based on interviews with service providers, most are more likely to be at the cooperation and coordination end of the spectrum. Services note that collaboration is resource intensive and as a result of resource constraints by all services the depth of relationship is lower than optimal.
Most services have agreements to support their relationships. Some have taken a long-term approach—for example Barwon Health services in Geelong, Victoria—and invested time and effort into planning and maintaining relationships. Barwon Health has worked with a range of community based agencies, including PHaMs services, to develop principles and case management and other protocols.
The definition of case management varies across services with many believing it is more akin to case coordination. Collaboration poses challenges for services from different sectors. The most common challenge relates to different perspectives on client needs and appropriate responses, especially between the medical sector with its individual curative perspective and the ecological, strength-based and client-led approaches used by the MHCB. Where a client has been referred by a mental health service it is common for that service to want to be in charge of case management. In many cases, however, PHaMs services report they are too busy to play an active role and this hampers effort. More work is needed to understand collaborative practice and systems and protocols to support combined work.
Services from all initiatives had developed agreements and protocols with other services.
Figure 5: Types of collaboration by PHaMs services
Figure 6: Types of collaboration by Mental Health Community Based services
Figure 7: Collaboration between service types—PHaMs
Figure 8: Collaboration between service types—Mental Health Community Based services
Figure 9: Collaboration between service types—Respite
Barriers to collaboration
Resource barriers
All services report high reliance on collaborative activity but they are frustrated by the lack of staff time to participate in such activity and the lack of funds needed to support collaborative activity. The connection with health services is still patchy and the relationship with General Practitioners (GPs) in particular is often developed when services are encouraging clients to connect with health services and accompany them to an appointments.
Time management due to pressure of client work as a priority, geographical distance of services; clashes in service style with Area Health Services; competition for available services such as Drug and Alcohol Rehab services; Availability of Housing services.
Practice barriers
One barrier to change is the lack of accepted formal pathways and referral practices between sectors, and a lack of common data collection practice between the state and non-government sector to support the referral of clients to needed services outside of the health system. One New South Wales Government health officer supporting collaborative practice between Mental Health Services and PHaMs noted that medical practitioners were accustomed to referring clients to individual practitioners and not to a service. Service boundaries (for example, PHaMs postcode boundaries) were also a source of frustration because referring medical practitioners did not have the time to investigate which service the client might be able to access. The lack of family data kept on clients by medical services is another barrier to referral to community services. If routine data were kept on dependents, for example, whether children and carers were involved, then referrals to supportive services for children and carers could be more routine and people in need of support could be offered service in a timely manner. All three FaHCSIA mental health initiatives felt frustrated by the lack of understanding of client need.
Notwithstanding the barriers, clinical and community service relationships are building. The analysis of survey data showed that 28 per cent of PHaMs clients were referred by medical practitioners, 20 per cent were referred to MHCB and 30 per cent by state-run mental health services for the NRDF component of respite. All PHaMs service providers interviewed said all of their clients were connected with health services even if they had not been when they entered PHaMs.
Lack of service sustainability
Short-term contracts for funded non-government services funded by the Australian Government also form a barrier to collaboration across sectors. Medical services in particular are reluctant to refer a patient to services when their longevity of service cannot be assured.
Having professionally trained staff whose qualifications and professional skills are familiar to those who work in health services—such as social workers, occupational therapists and psychologists— provides them with a sense of assurance that their clients will be appropriately cared for. Medical practitioners expressed service skill as a key concern.
The high turnover of staff in the community sector is also a barrier to enduring collaborative arrangements. Many collaborative arrangements arise from personal contacts and relationship development is therefore fragile. If a staff member leaves then it is not uncommon for collaboration to be undermined.
Funding and accountability requirements are also barriers since these tend to create a silo mentality and a degree of competition between services for the same funds. Lack of service depth also provides a disincentive to collaboration. MHR raised this issue frequently. A competitive culture also stifles collaborative effort.
Most community and non government agencies are continually competing for the same government funding resources. This creates a silo mentality within this service industry and therefore results in each agency attempting to meet its own service agendas rather than looking at working together for the benefit of clients.
The FaHCSIA Targeted Mental Health Initiatives have been instrumental in developing connections with the health sector, and services are sensing improvements in relationships and practices over time.
Maintaining effective lines of communication requires particular planning attention where the staff of many services work part time and are also often out of office providing service in other centres; Particular energy has been necessary to form positive relationships between non-government and government services, due in part to the perception by government-employed professionals that they have more responsibility and expertise in supporting clients. Non-government services have worked for a longer period of time with other non government services and are familiar with collaboration and partnerships, especially in rural regions where services are less available. More recently mental health teams have been more responsive to the establishment of partnerships and more effective lines of communication.
In summary while significant progress has been made, governments and the NGOs have continuing challenges. Ongoing efforts should be made across all levels to improve the understanding of the different roles operating within the mental health services system, to enable different services to work together and complement approaches.
High levels of professional expertise supported by professional development, training supervision and guidance
Service managers face the challenge of employing a mix of professionals to meet the demands of their client groups and their service delivery model. Employing this mix is the greatest challenge in setting up and maintaining service capacity and quality. However the success of a service does not only rely on professional and content skill. It depends on a number of attributes such as high interpersonal relationships and team skills, and the ability to work in various contexts and within a spectrum of cultures.
There is unequivocal evidence that staff skill is linked to service quality and client outcomes. Service providers report that the range of the responsibilities they have for collaborative mental health services requires a rich mix of skills. A large proportion of services have achieved this as figures 10 to 13 illustrate. Metropolitan services have greater access to a skilled labour market, particularly recent graduates and early career entrants seeking experience. Rural services find recruitment of skilled staff a major and continuing challenge.
All services have a high representation of degree qualifications, including those incorporating exposure to mental health issues such as social worker, psychologist, or occupational health training. Degrees cover a range of fields including health-related qualifications such as social work and psychology and nursing. There is also a good representation of other degrees covering areas such as education, management and health sciences with participants having post graduate qualifications, certificate qualification and courses in mental health. These qualifications, combined with the representation of certificate courses, means that in many services there is a rich mix of staff qualifications and capabilities. Many services also have staff with post graduate qualifications covering a range of mental health topics and other staff with certificates from mental health, disability and first aid courses. Comments provided on surveys showed that there are a number of services that have degree-qualified staff in non-mental health or health fields such as social sciences and humanities.
Figure 10: Most commonly held qualifications in Personal Helpers and Mentors Services
Figure 11: Most commonly held qualification in Mental Health Community Based services
Figure 12: Most commonly held qualification in National Respite Development Fund services
Figure 13: Most commonly held qualification in brokerage services
Major barriers to recruitment include non-competitive salary levels, short-term contracts and availability of staff with the right attributes. The right attributes was more important for MHCB as family-based services are more demanding and require higher levels of skill, particularly if they incorporate family therapy. Some MHCB services had a policy of paying staff more competitive salary levels by incorporating these in their funding proposals. They claimed that without that, they would not be able to staff their service. This is cited as a reason for fewer problems with recruitment and retention in MHCB services.
Poor staff retention rates are a serious problem and have their basis in the disparities between the Social and Community Service (SACS) award for non-government services and state government health awards. Services report that staff in their early career use the MHCB as a training platform and then take positions in higher paid government services. These staff report having a professionally rich and enjoyable experience with NGOs, which use the SACS award, but say they cannot afford to stay on the salary levels offered.
| Social and Community services worker award 2009 |
Full-time salary $ per annum |
Government award (Bachelor equivalent degress) |
Full-time salary $ per annum |
|---|---|---|---|
| Level 1, year 1 | 30,091 | Level 1, year 1 | 47,886 |
| Level 3, year 1 | 40,363 | Level 3, year 1 | 74,621 |
| Level 5, year 1 | 53, 510 | Level 5, year 1 | 87,148 |
Even assuming that the year levels do not have completely comparative qualification requirements there is still a significant difference in remuneration between the government and the non-government sectors. This table is consistent with information from survey respondents who have degree-based allied health qualifications. These respondents reported that if they were working for government their salaries would increase between $25,000 to $35,000 per year.
NGO services and staff express frustration at this situation. Poor staff retention increases administrative and system costs for a range of reasons—early career staff require more supervision, inefficiencies arise from loss of corporate knowledge, teams are disrupted, client service is disrupted hampering client ability to meet goals, resulting in service under spends. It is costly and time consuming to recruit new staff and new staff have to be trained to work within the service and within the field. Most causes of the remuneration problem are systemic. Services have no other sources of funds to improve the situation.
There is also a strong relationship between quality of care and the systems of staff guidance, supervision and support. All three initiatives had strategies for supervision and support to ensure quality of care and development of staff. The following example from MHR (figure 14) is similar to the strategies used across all interventions.
Figure 14: Measures to ensure quality of service—Mental Health Respite
The resolution of workforce issues is hampered by a lack of a strategic approach to the development of workforce capacity to meet a range of needs, and for ongoing development and support. High-priority needs include infrastructure development for national delivery of training programs including to rural areas, resolution of issues pertaining to salary and conditions
Evidence-based and outcomes-based approaches
Services should be able to articulate their service delivery models, identify the research evidence on which these models are based and continually review whether they are successfully contributing to outcomes by applying the models. This is important for three reasons. One, it ensures that appropriate models of service delivery have been selected and effectively implemented. Two, it helps clients who may need to be convinced that there is hope for them if they use the services through evidence that models of service delivery exist. Three, referring services need to have confidence when referring clients or enquirers that there are models and that the services are using sound principles of delivery. Services should use measurement approaches which provide evidence of client progress, for example, measures of family functioning, social connectedness and health and wellbeing.
The FaHCSIA Mental Health Initiatives are evidence based to varying degrees. MHCB services had evidence-based approaches and evidence-generating approaches as core objectives for the evaluation. Services under MHCB use sound evidence based on psychosocial interventions and further evaluate their effectiveness when implemented in the local environments. Examples of evidence-based approaches which services quoted include: Friends for Life, Carers Of People with Mental Illness (COPMI), Circle of Security, Attachment Theory, and the Positive Parenting Program ("Triple P") to name a few. Many staff voiced their appreciation that PHaMs was based on evidence of its effectiveness and they were proud to work with that model. MHR services were similarly established on evidence.
While MHCB had the use and production of evidence listed as part of its contractual conditions the research and evaluation component of their service contracts is not well understood and had been neglected by some of the services visited. However most visited had made serious efforts to evaluate the impact of their service on people and had engaged universities to assist in this effort. In other cases services were too small and/or too ill-equipped to research the impacts of their service. These did not understand the rationale for evaluating and they did not have internal research and evaluation capacity. In these cases services had made little headway in evaluation. While PHaMs do not have a research or evaluation role a number have developed relationships with universities and are participating in research. Decisions on research themes are made locally. While some MHR services had undertaken research and evaluation, it was more service and locally focused.
The role of evaluation and research at service level is not clear. FaHCSIA has not guided efforts by establishing priorities for research or developed a strategy to disseminate and promote findings. It is left to the services to undertake sector capacity development in their region and to promulgate findings through presentations at conferences and through academics publishing research. Many services are actively undertaking this role but the results are not necessarily taken up strategically by FaHCSIA. While the MHCB is highly beneficial to its communities, more would be achieved if there were more clarity of purpose for interventions and an organised approach to collecting and disseminating evidence. PHaMs is new as a service model and it is also timely for this service to look closely at the impact it has on clients and the service system. Longitudinal studies or cross sectional studies would be highly relevant in providing information about client progress with all services.
Potentially FaHCSIA could focus and mobilise research effort to further build the evidence base for successful interventions in varied Australian settings, including with Indigenous and other target groups. While, many individual services were participating in research partnerships with universities there is no current arrangement for such information to be disseminated to the program. Results of such research could be applied more generally through system and service policy and potentially service effectiveness and client outcomes would be enhanced.
A number of services were interested in national core data sets derived from management systems so a consistent evidence base could be established. This would require support from FaHCSIA for the use of management systems which would support collecting and sharing such data. Individual services and peak bodies were researching ways to better manage clients and report on outcomes.
FaHCSIA could contribute in significant ways to primary health care service research, and to service improvement, by fostering dissemination of evidence and debate on its implications. Not all services are in a position to contribute. Instead of making research a requirement for services it might be more effective to decide on priority topics and invite proposals for involvement on this research (perhaps even involving joint service-university action).
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8. Models of care
This section briefly discusses each initiative's service models, and focuses on issues in common. More detail on each initiative is in Part C.
As previously mentioned each initiative was designed separately to serve the needs of different high-priority population groups. However each initiative has similar philosophy and service principles.
PHaMs model of care
PHaMs, a voluntary service, adopts a strengths-based, recovery approach to supporting people with a severe functional limitation resulting from a severe mental illness. A strengths-based approach focuses on a person's strengths rather than their deficits. A recovery approach recognises that a person can live a satisfying and contributing life within the limitations caused by their illness. Recovery does not mean cure.
The model based on 'recovery' concepts used for PHaMs has proven to be sound in terms of meeting the needs of people with severe functional limitations arising from mental illness. Clients, staff and stakeholders report it is respectful and highly effective.
The PHaMs initiative is open to people aged 16 years and over, whose ability to manage their daily activities and to live independently in the community is compromised by severe functional limitations as a result of a severe and persistent mental illness. The EST is used as a screening tool for entry into PHaMs. Participants do not require a formal clinical diagnosis of mental illness to enter, but they may be able to access clinical treatment during their time in the PHaMs.
PHaMs eligibility criteria are universally supported. The PHaMs is considered to have provided increased access to clients who could not access other services, especially those who have become disconnected from services because of, and those who fell through, service gaps. This includes those aged 16 to 18 years. Although this group have been Child and Adolescent Mental Health Service (CAMHS) clients they are unable to progress to adult mental health services.
A review of the use of the EST has been recommended by a number of services which are supplementing it with tools to provide better outcomes measures.
Some suggested minor amendments to the EST are:
- when considering eligibility allow clients more time for:
- signing confidentiality agreements for information sharing;
- making undertakings to address alcohol and drug issues where co-morbidity exists;
- to consider eliminating geographical restrictions on client access.
PHaMs is generally a highly effective model meeting a clear need. Proof of this is that many services have to manage demand and have waiting lists. This program should be considered by government for considerable expansion. However, in rural areas it works less well as skilled staff and supportive service structures are not readily available. This model of care has been difficult to implement in rural areas—there is enormous difficulty in establishing and operating services. The supply of trained staff who are willing to work in rural areas is a major issue as is the lack of supply of services to support clients. FaHCSIA has, as a consequence, recently amended the model for remote Indigenous communities. This had not been applied in services funded in rounds 1 and 2 of PHaMs, which are the focus of this evaluation.
Many stakeholders would like to see considerable expansion of PHaMs to better meet identified service needs.
Mental Health Community Based Services
This initiative funds targeted projects to support families, carers, children and young people affected by mental illness. It has a range of objectives which each project addresses differently. One objective is to support service research through the development of new evidence or to test evidence which has been previously developed. Most services have been attached to a parent organisation which includes a range of existing MHCBs already serving families or particular population groups such as Indigenous or CALD. Another requirement is for sector capacity building by sharing evidence across the community sector, including service partners.
The youth and family centered model of care for MHCB is highly effective in a range of ways. It has allowed services to design interventions to fill gaps in services for groups at risk of developing mental health problems and it give each service the flexibility to respond to individual and family needs rather than requiring the client to fit into a single service model.
The eligibility requirements as set by FaHCSIA are broad. The priority is for youth and family services and each service works within the eligibility parameters of their funding proposal, such as children aged 8 to 15 years and their families, or children who have parents with a mental illness. Services expressed satisfaction with this arrangement as they are able re-negotiate eligibility parameters when needed.
The role of the innovation, research and evaluation component of MHCB service contracts is not well understood and had been forgotten by some of the services visited. Some are making serious efforts to evaluate the impact of their service and have engaged universities to assist in this effort. In other cases services are ill-equipped to research their impact and have made little headway in this regard.
The MHCB model has also been deployed in an innovative and effective way for various target groups such as Indigenous and CALD, work with schools, work with carers, families affected by mental health and those affected through a combination of mental health and drug co-morbidities.
MHCB is not large enough to have a significant population reach so while it is a highly effective model it is not deployed widely enough to have a major population health impact. Indeed, the service is not visible to state and territory governments. While these levels of government might be aware of the parent service, particularly when the mental health component is attached to a large organisation, they are not aware of the contribution being made by FaHCSIA to mental health in the communities they serve, or to capacity building in the community and in other sectors.
This model has enormous potential as a tool for innovation and has produced important information for prevention and early intervention in mental health for youth and families, particularly on the needs of groups such as early childhood (those aged under 8 years). Ideally it would be expanded and used in a targeted way for service capacity building and development of evidence. Its approaches could be incorporated through PHaMs and MHR but with attention to the youth and family target group.
The Mental Health Respite service model of care
The MHR had two service components—brokerage and NRDF. The aim is for these two arms to work cogently and harmoniously to manage supply and demand. Although the design of the service arose from community consultations the current model has been less successful than hoped. The range of services offered under the model are considered necessary and appropriate but their depth and availability depends on more planning and cooperation at the regional level than exists.
The model presents many benefits, although it has not worked optimally across many regions in Australia for a range of reasons including:
- Provision of carer services for the mental health field is a new enterprise with little experience by services in conceiving and operating a suite of services to meet need. Services have also not been able to penetrate the market to inform carers about the service and enable them to participate in shaping the service. The term respite is not relevant to many carers who believe that term relates to live-in services.
- The brokerage model is delivered by many agencies who also deliver disability services with the disability model exerting too much influence over thinking and planning for mental health services. This has resulted in a predominance of short-term respite with longer-term planned care, which is likely to be more attractive to many carers.
- Competition between NGO services for funding over many years has reduced trust and the desire to collaborate.
- The model has introduced complexities in the needs assessment and governance processes between services resulting in duplication of functions, delays in access and available services not being used.
- The guidelines are too complex which has resulted in varied interpretation across the sector and across Australia.
- The eligibility criteria are too restrictive for carers of people with mental health problems and many carers with legitimate needs cannot access MHR. These include middle aged people who have children with mental health problems, children who are primary or secondary carers and adults with mental health problems who have families.
- Conversely the inclusion of autism and intellectual disability within the service pose logistical and service design problems. People with an intellectual disability have different care needs and many services advocated not including them or at least reducing the proportion of clients with disability in their contracts over time.
- Many services noted that a more useful approach might be to provide a secondary consultation service to services designed to meet the needs of those with intellectual disability to better address their needs.
It is timely to consider other options for respite service delivery models incorporating the insights about carer needs and priorities for the service that have emerged over time. This model needs to be redesigned, to streamline and simplify it. The authors suggest one carer support model, and dropping the name 'respite' which has connotations which deter mental health carers from accessing the service. Flexibility in delivery models should be retained.
New guidelines should be developed. Carer support services should be encouraged to have responsiveness to client need as the overriding principle, and care should offer options with flexible respite and planned long-term care being high priorities.
Services to mental health clients need to incorporate a wide range of support for carers which are not always currently available or accessible. These could include individual supports or support through collaborations of services. Evidence suggests that carers should have access to more planned long-term support need. These include education about mental illness and psychosocial rehabilitation as well as time out for carers by providing activities and programs for clients and/or providing assistance with direct care so carers can be released for other activities. Brokerage funds should also be available to meet a range of emergency needs as households can become impoverished by the lack of ability of a carer to work or to keep households running smoothly because of their caring responsibilities.
There should be more emphasis on indirect rather than direct support under the guidelines as these have been proven to provide more appropriate support for carers of people with mental health problems. There is some evidence that all of these activities are occurring across regions but they are fragmented and a full suite is unlikely to be fully available for most clients.
The eligibility criteria need to be opened up. They currently exclude parts of the population with high needs—for example, children who have parents with mental illness (some of whom are in a primary or secondary caring role), young carers, parents or carers with dependent children who have mental illness and who are younger than 65.
There is a disproportionately high representation of carers with intellectual disability in the Brokerage stream which is an unintended result. Service providers are questioning the inclusion of intellectual disability and autism because they require different supports and there are already systems available for those with disability. Services note that these clients would receive better service under these systems and that these arrangements could be backed up with MHR services offering secondary consultations on mental health to those providers.
Consideration should also be given to opening up access points for carers. All of FaHCSIA's mental health services and potentially other services funded by FaHCSIA could support carers. Market penetration is key and an ongoing problem for all services providing support to carers. The points where carers access other services are a point of potential access.
A family focus to models of care
The MHCB model of care is underpinned by the concept of 'family focus'. PHaMs and MHR are not and service providers regularly raised their desire to be able to provide family focused services for a range of reasons.
Family focused services are services in which members of the family and the family as a whole are seen as clients with needs in their own right and not just part of the treatment for the individual, however, addressing family needs may contribute to better outcomes for the person at risk of or with mental health problems. It may also contribute to better outcomes for the family as a whole, including better family connectedness. Moreover, a family focused approach does not preclude working with the mental health client in parallel. The focus taken depends on each situation and the most appropriate approach would be determined through client and family interviews and assessment. Figure 15 illustrates a possible spectrum of care within a service. The most family focused services are those that operate at the right hand end.
Figure 15: Degrees of family focus8
8 - (Adapted from Enhancing the Wellbeing of Families affected by Drugs, Findings on the evaluation of the NIDS strengthening FamiliesMeasure) Courage Partners, 2007
PHaMs and MHR use individual client-centered models of care. They have noted that effective client-centered care would include attention to their family circumstances and environment. Collective family wellbeing is a protective factor for primary and secondary prevention of problems of all family members. Many clients and their families accessing the services provided under the Targeted Community Care (Mental Health) Program have complex needs and high levels of personal and socio-economic risk factors. An individual client may progress more effectively if family risk factors were reduced because this would increase the capacity and stability of the family unit by building protective factors for the whole family. If such needs were assessed at the point of entry then appropriate timely and inclusive action could be taken.
Both PHaMs and MHR identify children of clients with mental illness whose needs cannot be addressed. Some of the bigger services which auspice PHaMs and MHR manage a range of services that can often take the needs of family members into account. However they note that direct support for a more holistic and coordinated approach through each service would be more responsible and effective than the current arrangement which depends on places in their own or other services being available.
FaHCSIA has experience with the family-based approach through MHCB which has used a range of effective responses to family needs in a variety of situations. If all services used this approach then the following implications for service delivery would need to be considered.
- Some services could offer all service types, incorporating attention to all population groups. More systematic attention could be given to young people and families and to carers and this could increase the reach of mental health services to those at risk.
- Some services may offer to assess family needs if appropriate but refer to other services if they are available in the region.
- Collaborations of services where each delivery agency may choose to focus on one or two service types but to ensure that the three targeted mental health initiatives are available among them.
In summary, family-centered care has been requested by services and stakeholders. Depending on the extent to which services took this approach they would need to understand the implications for service selection, resourcing, staffing and organisation of services. Many services could address family-centred needs by increasing capacity or by working collaboratively with other services. These arrangements should also be influenced by local and regional planning.
In terms of service alignment the only real differentiator between the initiatives is the differing target groups, but the client risk factors and the service strategies and overall client outcomes are remarkably similar. Many services would have the capacity to meet the needs of all target groups in a more efficient and seamless way if they were combined.
Conclusions on outcomes from mental health service initiatives
The FaHCSIA Targeted Mental Health Initiatives are now established as an important contributor to the mental health service system. The number of clients attending relatively new services is testament to the professionalism of these services. Individually each service type is operating professionally, has attracted qualified staff and has established a role in a complex and fragmented service system. All services cite areas for improvement in their own operations and in their capacity to work as members of the service system.
PHaMs is seen as highly effective by clients and all stakeholder groups and it has made visible contributions to the service system for people with severe and persistent illness. Minor evolution in initiative design and funding levels would substantially increase its effectiveness.
MHCB is also making a major contribution. It is integrated with other services in the field and providing high-quality services for families and young people. MHCB services are generally soundly based on evidence and are contributing to the evidence base for mental health promotion, prevention and early intervention through their evaluation work. However the size of MHCB means its reach is limited.
The MHR service is seen as providing some essential services by carers who access it, but in many areas it is not reaching adequate numbers of carers or providing carers with the spectrum of support required. MHR would benefit from simplification, changes to eligibility and changes to the service delivery system, to support more coherent approaches to care. While 19,000 clients have been assisted by MHR, more in-depth service is still sought, especially in planned care.
Many of the services have managed to influence or alter the underlying family and social infrastructure to support a desired outcome. This has included building parental skills, reducing social isolation by improving social and community involvement and improving the personal and collective resilience of family members.
Service alignment
The services are similar in philosophy and approach. The key differentiator is the target group served. MHCB has the opportunity to reach members of a family who also have a mental health problem or who are affected by mental health problems. PHaMs and MHR service providers also believe that individuals and families would be better served and problems more effectively addressed if they could respond to family member needs.
These initiatives could be offered as one program with service providers who have the capacity and for those who do not the ability to access funds to purchase such services for clients.
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9. Policy and system factors affecting service achievement
Collaboration
No single provider is equipped to provide all services required by clients. The Fourth National MentalHealth Plan and the underpinning state and territory plans all reinforce the need for collaborativeapproaches to address the range of client risk factors, including housing needs, disconnection from services, social isolation and poverty. Collaboration between providers to offer a more comprehensive range of services for clients and to negotiate client case work is the underpinning principle of all three FaHCSIA Mental Health Initiatives.
Stakeholders noted that while the policy leadership of collaborative effort between the health and community sector, through state and territory plans and strategies, plays a key role in developing more effective and responsive approaches, it will take time and a great deal of effort to break down traditional setting-based approaches to care.
Strong barriers generated by historical practice, culture and unsupportive systems still exist between the health sector and the community sector. These are disrupting care pathways and failing to address clients' social and economic needs. This is an international phenomenon as this comment indicates:
It is apparent that health and social care organisations approach new partnership arrangements with well-established perceptions—both positive and negative—of each other these perceptions in particular the point of tension, are often expressed in terms of culture. Further, it is clear that culture plays a major role in the success or failure of partnerships. The process of creating and sustaining new partnership forms between health and social services thus needs careful attention to culture.
Most stakeholders made this point and also noted that while these barriers are breaking down they still need to exert concerted and continued effort at all levels because client progress still depends on the development of personal relationships between clinicians and services. Partnerships are therefore still fragile.
The development of the community mental health programs, especially the PHaMs Program, has challenged many assumptions and processes of mental health services, particularly who "owns" mental health services and their clients. There have been variable responses from health services, many of whom refuse to refer clients with others taking time to be convinced. (Service respondent).
Lack of understanding of role and contribution of various service types
A major barrier to collaboration is lack of understanding of the contribution made by the service approaches and roles of the different sectors. This leads to barriers to seamless and informed client care.
The term 'community mental health service' has various interpretations. For many in the health sector it means state and territory funded consumer focused 'specialist' services such as residential rehabilitation units, community crisis teams, outpatient services, community mental health clinics and child and adolescent mental health services, as well as primary health care clinical services provided by doctors, psychologists and other clinical professionals.
For FaHCSIA and many other community mental health programs the term relates to services that seek to improve the capacity of individuals, families and carers affected by mental illness to participate socially and economically. This is achieved through: supporting individuals on their recovery journey by improving life skills and quality of life; building resilience of families (including children and young people), increasing skills and knowledge and by supporting carers to maintain their caring role.
While this issue of role clarity is gradually being broken down it still poses significant barriers to effective psychosocial rehabilitation. Barriers between health and community service sectors remain high and need time to be completely broken down, as the following survey comment illustrates.
Sometimes GPs, psychologists and psychiatrics, seem to have little knowledge of individual psychosocial rehabilitation. They are unaware of evidence that demonstrates the enormous benefits for clients and the evidence that these kinds of services can provide an average reduction of more than 50 per cent in cost of care due to reduced hospitalization. In some cases they may be unaware of best practices in regard to self-management and chemical treatments. (Survey respondent)
Government representatives in all states advised that despite all efforts, significant barriers remain between the medical and community sector. Many of these barriers relate to understanding and respecting population health approaches and the importance of the community sector in addressing the social determinants of health.
Organisations that have built productive working relationships with the clinical sector report that the following list of factors was instrumental in building trust and the confidence that very ill clients would be appropriately supported:
- The experience and existing profile of the organisation in the mental health services sector.
- Staff with qualifications in allied health (especially occupational therapy, psychology, social work and nursing, especially those with experience in mental health). These staff have shared professional experience with clinical staff enables them to negotiate and explain the contributions of mental health services. They also trust the professional capacity of staff.
- Longevity of the program, and expected longevity—there is a distrust of services which are funded in the short term combined with the stability and size of the organisation (how long it has been there, how many clients can it support).
- Relationships which are pre-existing or experience of similar services.
- Reports from clients on their achievements or benefits acquired under the service.
Meeting some or all of these factors does not guarantee that relationships will be developed within the clinical sector. This depends on the culture of the mental health service involved and the depth of service capacity in the region. However they are factors which should be taken into account when designing system change.
Community Mental Health Service stakeholders are making a concerted effort to establish service agreements, service pathways and collaborative relationships between services to ensure client needs are attended to as seamlessly as possible. However they noted that this requires skill, persistence, work at all levels—Australian Government, state and territory governments, service level and staff team levels—all of which requires resources and time. Services are not currently funded to support this level of effort. This should be addressed by all funders so comprehensive and effective pathways of care can be developed.
Services noted that there is limited acceptance and understanding by the health system of the role of community services in psychosocial care, especially with understanding:
- the contribution of psychosocial services to recovery from mental illness;
- the role of family and community in rehabilitation and health;
- that collaborative effort is required to recover from mental illness.
Although the services provided under the Targeted Community Care (Mental Health) Program demonstrated a high degree of experience and competence in developing collaborative relationships with other service sectors, success will remain inconsistent and fragile unless collaborative approaches are supported by institutional and system policy and institutional arrangements.
While some state governments have introduced strategies to break down the barriers between sectors—especially between the health sector and NGOs—they will take time to resolve. These strategies include conducting education seminars in Western Australia, employing coordinators in Queensland and employing clinical coordinators in New South Wales (who have been working on these strategies for some time). Each of these states reports some progress but acknowledge that collaborative arrangements are still developing. Much more thinking and further strategy development is needed and this should involve the community service sector.
GPs are an important referral point by all services but relatively few referrals came from them. Relationships are evolving and it is likely that it will take some time for good practice to become clear and for close collaborative arrangements between GPs and community mental health services to become the norm, especially for prevention and early intervention. System-based strategies to engage GPs need to be developed.
Changes in service system operation and improved pathways of care are difficult to achieve. Service participants need strategic policy and funding support to underpin local effort. Attention needs to be paid to the qualifications of staff, system level changes such as referral practices, and professional development of staff so they understand the roles of various system players. Such action must be instigated at the Australian Government and state and territory government levels. Change strategies should be informed by the experiences of services as outlined above.
Workforce challenges
Services express frustration in having to contend with the ongoing difficulty in attracting and retaining a suitably qualified workforce to provide services and noted that this is an ongoing and pervasive problem. Service providers noted a range of problems, including those mentioned above, arising from poor remuneration, high workloads and short-term employment arising from funding contractual arrangements.
The Community Mental Health Services support clients with complex needs so staff required a commensurate skill mix and personal capabilities to respond to clients and the range of other service providers. Regardless of their entry qualifications staff need additional on-the-job training and preparation to work with clients. As well the need for collaboration with other services requires staff to be able to work in teams, negotiate and advocate on behalf of their client, problem solve and potentially to deal with conflict.
Overall the supply of staff in metropolitan areas was reasonable but many services had to rely on early career staff who were prepared to accept low remuneration in return for experience and career development. Supply of staff in rural areas is highly problematic and service providers reported having difficulty in acquiring staff with appropriate qualifications. In remote areas it is difficult to attract people at all and some services have had to delay operating while they build skills of local staff. However, many metropolitan service providers spoke of the difficulty of recruiting staff with the expertise to work with youth and families and with clients with mental health and drug and alcohol co morbidities. Staff with Indigenous and CALD experience were also difficult to attract.
Ongoing professional development is a continuing need as mental health and related issues are so complex. Staff usually participate in a range of courses when they start employment (for example, mental health first aid, keeping professional distance, recovery approaches and case management). However, more training is needed, including, potentially, on topics such as alcohol and drug co-morbidities and therapeutic interventions.
The capacity to provide and sustain training, especially with early career staff is limited. Services spoke of the inability to meet needs, the unavailability of courses when required and, in the case of rural and remote services, the inability to meet professional development needs.
Services attached to larger organisations usually had more opportunity for continuing development, but this still constituted a fairly significant challenge in terms of time and resources.
Clearly many workforce problems would diminish with a change to salary structures and conditions. Other initiatives, relating to workforce supply and ongoing development, would ameliorate some problems. These initiatives should include:
- Developing strategies to build the workforce, particularly recruiting workers who speak a community language. Attention should also be given to building the capacity to provide services to Indigenous and CALD clients, and clients suffering from trauma such as refugees.
- Providing affordable, accessible and timely training for staff and making this available nationally, including in rural and remote areas. Providing e-learning is one possible approach and there are others. Such training should incorporate recovery, prevention and early intervention strategies and work effectively with clients with mental health and alcohol and drug co-morbidity.
- Supporting the needs of the workforce to collaborate with psychosocial services to provide holistic care. This could target clinicians and other services such as employment, housing, corrective services and educators.
Much of the foundation for such initiatives exists. Many peak bodies have been funded to develop courses and resources and they might make them available. Likewise services have developed courses and are likely to make them available, especially if they were remunerated for their development work. An e-leaning capacity, called the Mental Health Pod, has been developed for mental health. This was funded by the Australian and state governments and is currently available to government employees only. This initiative might be able to be extended to non-government providers of mental health services. Alternatively there are many other primary health care providers who may be able to host such a platform.
Service planning
The FaHCSIA Mental Health Initiatives have formed another set of service opportunities in an already complex, dynamic and fragmented service system which is already difficult for both clients and services to negotiate. Quality, depth and extent of services available in a region to meet client needs is a key factor in the success of services generally and particularly for rural and remote services.
The FaHCSIA mental health initiatives were welcomed as they provided much needed opportunities in a limited and stretched mental health service system. Many service providers expressed frustration at the fragmentation of the service system, however, and the proliferation of small service providers whom they considered required more support to operate effectively in the field. They would like a more thoughtful approach to service planning, selection of services and decisions of location of services. Providers commented that the selection and placement of services was often less than optimal in serving client needs in a region. Some areas were well served while others were not served at all, even though they may be geographically accessible. Service providers and state and territory governments want more consultation with FaHCSIA on service needs and placement and want to involve FaHCSIA in discussions on selection criteria, service placement and service size and how services can operate more seamlessly in the field.
As well, while providers accepted that regional service planning involving Australian Government and state and territory governments was complex they had a sound understanding of the spectrum of services available and believe they could offer regional wisdom to decision making. Many providers suggested that better decisions might be made if FaHCSIA engaged them more to advise on local and regional needs. It was noted that at the inception of the strategy FaHCSIA consulted and communicated with them more actively than they now do. They would like more involvement especially in a period of service reform.
Service planning is complex and time and resource intensive. It requires system support. Geographic Information Systems (GIS) can generate complex models of population data and service availability and identify gaps—all valuable aids for understanding needs better and supporting further planning and research in the community mental health sector and at localised levels. One GIS tool, called Health Landscape, applies these approaches in primary care (it is available at http://www.graham-center.org/online/graham/home/tools-resources/healthlandscape/gis-pc.html). Health Landscape is being assessed for its use in Australia by the Australian Primary Health Care Research Institute at the Australian National University (www.anu.edu.au/aphcri).
Significantly improved data collection and sharing across services will also be required. This will include improved record keeping across the community sector and the capacity to link social data with clinical health data. GIS may also support this work.
Service size, capacity and sustainability of services
Services that seem to be most effective had a long-term presence in some form or another, and highly qualified staff whose role is respected across systems and in mental health. Some parts of PHaMs were attached to services that had been offering mental health services to the disadvantaged for many years, and some were attached to NGOs that had been offering employment support.
Services reported being highly dependent on funding from short-term grants. Many stakeholders noted that for PHaMs and MHR many services were very small, had disproportionate administrative costs, and did not have the depth of experience needed for sophisticated psychosocial rehabilitation work. This jeopardised the standing of psychosocial services generally. Furthermore it contributed to service complexity making service planning and collaboration more difficult.
Service capacity in the regional (rural and remote) areas
Rural and remote areas usually had impoverished service environments and this almost seems to be an insurmountable barrier to quality service.
Implications include:
- The necessity for varying the service models so they can work more effectively in those environments. Further models for rural and remote service might need to be developed. Identifying and funding service capacity supports such as systems, training, and staff mentoring;
- How to provide access to sufficient services for clients. E-health strategies might be considered as well as support for travel;
- How to generate better labour supply including providing incentives for local people to become trained to deliver mental health services.
This issue of capacity warrants separate attention and could be considered in concert with general primary health care service reform.
Additional funding for staff support might be required. However if services are attached to larger providers some expansion of service models could be implemented. Research and evaluation on models already developed is required for service planning and evolution.
Geographical boundary restrictions on eligibility
Both PHaMs and MHR have geographical eligibility constraints based on postcodes or Home And Community Care (HACC) boundaries. MHCB has no such constraints but is affected by them in referring clients to services that do.
Services were not clear on the rationale for designating boundaries but indicated it was possibly to:
- prevent clients from double dipping;
- ensure that areas of real need were covered;
- ensure that services did not 'cherry pick' the easiest clients.
If these were the objectives then it is not clear that they have had those intended effects. Those concerns might also be met by guidelines.
Issues which have arisen for services relating to centrally imposed geographical restrictions include:
- Post code or other restrictions that may cut across long-standing service arrangements for example, those providing a range of services to Indigenous or CALD groups where family and community networks are served. One Indigenous service claims that NRDF boundaries cause puzzlement and frustration from Indigenous clients who use this service provider as the dominant Indigenous service in the region, and who legitimately access services other than NRDF but are precluded from using that one.
- Post codes sometimes cover business districts or other areas which have few potential clients.
- Clients within easy reach of a service provider may be ineligible to receive services and left without an alternative service to use.
- Demographic characteristics of areas are dynamic and circumstances can change markedly in periods of three to five years so the service is left with eligibility restrictions that are no longer relevant.
- If clients move to the next suburb they may not be able to continue with the same service when it is in their best interests to do so.
- The geographical coverage posed by postcodes is often illogical in terms of actual client access because of factors such as actual distances to be travelled, flow of public transport and areas of high need.
- In subsequent rounds some PHaMs service providers have to travel through other PHaMs catchment areas to access their own area.
- The designation of areas poses problems for referrers, especially mental health services and GPs who find it confusing and time consuming to understand the system. This affects their willingness to refer.
- It makes it much more confusing for referring agencies that are likely to pick the service most convenient for the client which may conflict with eligibility criteria.
MHCB, which does not have these geographical access restrictions, has not raised any particular concerns.
Service providers claim to know their environment, know the services available and the public transport systems. It would seem preferable for them to have guidelines but be able to make judgments based on need and include these decisions in reports.
Time for establishment of services
Services have only been operational from 18 months to 2.5 years depending on their inception date. Services report that it takes up to a year after acceptance of a government proposal to get established. Establishment processes include: developing policies and procedures; finding premises; recruiting staff (this tends to take the most time); marketing; and securing involvement from other agencies as referral sources and service partners. The establishment time is reduced somewhat when a new mental health service had a parent organisation with substantial community presence and a reputation in mental health or a related field like unemployment or child protection. However as most community health programs were generally offering different approaches and operating under an unfamiliar brand, it took time to be accepted as a bona fide service.
The grant period of three years to get up and running has proven to be too short. Before being fully operational, most service providers found they had to warn clients and referring agencies that continuing service depended on a new grant being awarded. Services are in this situation currently and are pressing for early notice about the future of the program or of services. Many report that state grants provide more certainty—there is an understanding that funding will continue unless government priorities change. And in most cases contracts will be modified to meet emerging demands. Service providers would like the Australian Government to consider this type of arrangement because it offers more certainty. Certainty in continuation of a service is especially important for vulnerable clients and some stakeholders, particularly state governments, considered it unethical to not have more predictable arrangements.
Management of targeted mental health initiatives
Services were questioned on what improvements they would like to see in the design and management of the initiatives. Comments on individual service guidelines have been incorporated into previous sections on service models and geographical eligibility restrictions. They range from very few suggestions for improving PHaMs and MHCB to numerous suggestions for improving MHR. Suggestions provided included the desirability for outcomes based reporting, feedback on how a service compares with others (that is, the ability to benchmark services), and more funding to support the time and resources needed for collaboration and travel.
Overall, comments on the initiatives were positive and services were careful to say their views should not overshadow their appreciation of FaHCSIA's professional and flexible approach and their appreciation that 'FaHCSIA had a sound understanding of the business they were in'. Comments below reflect these views:
I think it is the best program ever developed because of its openness to ideas and flexibility.
I can't suggest changes that would improve the design and management. I think that the online reporting, data collection assessment tool, helpdesk support, communication from FaHCSIA managers, milestones, have been efficiently managed and all procedures are not difficult for service providers to carry out.
All is good and I believe that the emphasis on client and not administration is important to the culture and delivery of the program.
None. I think this is a beautiful program!!!
Overall, we have been very happy with the design and management of this FaHCSIA program and with the level of assistance and support from our contract manager. The overall management has allowed us to focus on the clients without an over-emphasis on paperwork whilst still maintaining thorough records/files. This has enabled us to give a much higher quality of service to our clients which is extremely rewarding.
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Part B: The Way Forward
Possible future directions for FaHCSIA under the Fourth National Mental Health Plan
FaHCSIA's formal role in the national mental health effort has been recent and over time there has been more clarity on how FaHCSIA can best contribute. The evaluation of the Community Mental Health Initiatives has highlighted many issues which can be taken forward by FaHCSIA as part of its own contribution to the implementation of the Fourth National Mental Health Plan, including whole-of-government contribution.
The following broad system program logic was conceived to clarify FaHCSIA's role under the Fourth National Mental Health Plan as a partner in the national whole-of-government effort. It was based on an analysis of the conceptual frameworks and priorities outlined in that Plan. The overarching program logic provides the framework for determining possible future direction for the programs FaHCSIA is responsible for to support the achievement of their program goals and to support the priorities of the plan. The findings from the evaluation also inform the specifics of policy action discussed in this chapter.
Figure 16 outlines a system program logic representing the overriding logic contained in the Mental Health Plan and Figure 17 outlines a system schema broadly illustrating FaHCSIA's role in the FourthNational Mental Health Plan.
The system schema highlights the important relationships and interdependence between policy and system development, service development and the target group outcomes desired as a result of system and service improvement.
National and state policies, system realignment and service capacity development form the enabling environment for improvement in mental health and wellbeing outcomes for a range of priority target groups under the Fourth National Mental Health Plan. Changes in outcomes for clients at the population level are dependent on changes in policy and funding and the design and operation of the service system.
Figure 16: System program theory
The system schema has been conceived from the perspective of FaHCSIA's role in mental health effort. It also includes thinking about requirements of the Fourth National Mental Health Plan, underpinning plans at the state level, other relevant policy arenas, for example, social inclusion policy, population health, national health reform priorities. It has also been informed by consultations from the field. Of necessity it is a concise representation. It represents three broad arenas of action with the first two contributing to an enabling environment to reduce the risks of mental illness and provide appropriate supports for those in need. These are:
- national policy and system development—the strategic policy and system arrangements underpinning action on a national and state/territory level;
- service system factors ensuring individual services are relevant, responsive and collectively provide seamless accessible care pathways;
- outcomes sought for clients, especially for designated target groups for services.
Figure 17: System schema
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10. Findings that guide the future policy approach of FaHCSIA
- The community sector is advocating for greater FaHCSIA contribution to the policy and strategy at the whole-of-government level and for FaHCSIA to provide more leadership to the community sector in a time of dynamic system reform.
- FaHCSIA is seen by stakeholders as being responsible for providing leadership in, and impetus to, psychosocial rehabilitation nationally and providing significant additional capacity to the mental health services effort. Non-government sector stakeholders have welcomed FaHCSIA's involvement seeing it as consistent with and complementary to the large number of prevention, early intervention and targeted support programs already provided through other FaHCSIA and state/territory programs.
- Community managed models have been highly successful in supporting the key priorities of the National Mental Health Plan and in achieving sound outcomes against their objectives.
- These models have added to the evidence of effectiveness of psychosocial approaches in the community setting, created innovative models of prevention and early intervention and demonstrated the effectiveness of recovery approaches in the Australian setting. Learning from this effort should be shared at all levels.
- Initiatives have also highlighted issues which must be addressed for the system to work coherently, for example creating effective pathways of care across sectors, and in many cases made headway in creating solutions at a local level.
- Many funded projects are bridging the philosophical and practice gaps between the medical sector and the community sector and also highlighting issues for more national and state policy and action. However, much more work is needed to break down cultural differences in service approach between clinical and community oriented services.
- Projects have demonstrated that service interventions can contribute to system change through enhancements to collaborative practice but that the influence remains local unless there are policy and system changes at the national and state level.
- Access difficulties exist because of the lack of services and difficulties of access to available services by people in rural and remote areas, Indigenous people and CALD groups need priority attention.
In keeping with the overarching logic, this report articulates the individual initiatives and service level outcomes with suggested improvements. However there are key system and policy elements that FaHCSIA needs to address if the overall policy and program objectives are to be met. The key change will be for FaHCSIA to focus on the system of community mental health, in particular:
- how the existing system can be sustained and improved particularly in reach and coherence;
- how the essential and unique contribution of the community sector in psychosocial services can be better understood and focussed in the national policy context.
Workforce
Policy frameworks, mental health evaluations and consultations consistently raised the development and maintenance of workforce supply and quality as a high priority for developing high-quality sustainable mental health services. It is clear that an adequate, quality workforce supply is a continuing challenge which greatly undermines the capacity of the system to work optimally. The consultations and the literature confirm that capacity gaps affect all levels. Current approaches to workforce development are piecemeal, fragmented and unsustainable.
Service and program requirements should drive workforce planning and strategies To do this effectively, workforce development must act at a number of levels:
- strategic systems level
- organisational levels
- team/individual levels.9
The community mental health sector is complex and has close links with clinical and related service sectors. Key considerations in developing workforce strategies include:
- maintain an adequate workforce across the sector in terms of skill mix, distribution and adequacy to support the needs of high-need groups;
- manage issues arising from government/NGO staff working side-by-side—for example, taking account of factors such as relativities in wages and conditions in different sectors for workers doing similar jobs;
- deal with professional and support staff who are playing separate but equally important roles in achieving client outcomes;
- identify the mix of professional and personal skills that different categories of workers need;
- ensure that the need for worker flexibility and multi-skilling is met;
- implement approaches to ensure that all workers can operate effectively in cross-professional teams to support case management and quality of care;
- establish appropriate education and career pathways and incentives for workers to improve their skills and maintain their professional competence;
- improve opportunities for 'on-the-job' learning and personal development.
Action by FaHCSIA at a systems level, in conjunction with other COAG members, could provide policy, contractual and resourcing levers to improve functioning at all levels of effort and therefore to enhance services offered by the Australian Government, state and territory governments and NGO providers. Initiatives such as e-training, especially for rural areas, providing basic ongoing courses for 'just in time' training, and specialist programs in fields such as substance abuse and family therapy would dramatically increase access to training nationally.
FaHCSIA, by having a strategic approach to the development of workforce capacity to support psychosocial services, could make a significant contribution by harnessing, linking and mobilising existing training programs and resources.
9 - Models of Workforce Development, NCOSS, May 2007
Priority areas for action from state and territory governments, NGOs and service representatives are outlined below.
National supply and working conditions
- improve the supply of workforce at all levels—current approaches are inadequate to address demand surges posed by emerging programs such as those being dealt with by FaHCSIA;
- deal with short-term funding arrangements for the NGO sector that result in insecurity among the workforce and lead to retention difficulties;
- attend to differences in salary and conditions between government and NGOs that result in their loss to the government or other sectors after initial training in the non-government area.
Development of skills to work collaboratively across sectors and professional groups
- develop a better understanding of the skills and experience required to undertake the complexity of the work and deliver quality mental health services to inform workforce development effort and qualifications required;
- develop the ability of different professional groups (and different sectors) to contribute to holistic care and to prevention and recovery services;
- update curricula to incorporate understanding of, and experience in, recovery at undergraduate levels (university and TAFE) for relevant professional groups.
Infrastructure development
- upgrade the training delivery system for professional development to provide a suite of essential training as a minimum requirement;
- improve the access to professional development by supporting e-learning and delivery which will provide a basis for high-quality, predictable, sustainable and 'available as needed' training;
- the need for positive action on a strategy for rural and remote areas for improving supply and retention, for example, scholarships, marketing, incentives to stay, career pathways, regional recruitment;
- create and implement strategies for Indigenous, CALD and peer support workforce development;
- build innovation in, and develop evidence to support, workforce development in mental health;
- develop strategies to support collaborative service across the sector—especially between health and community services;
- improve the capacity to respond to high-priority needs (for example, recovery, prevention and early intervention strategies) and to work effectively with clients with mental health and alcohol and drug co-morbidity.
Service system development
Collaboration aims to provide more effective pathways of care for clients and to ensure that the range of risk factors relating to their mental health problems is addressed. Stakeholders noted that the policy leadership of collaborative effort between the health and community sector through national and state/territory plans and strategies plays a key role in authorising changes in practice in the mental health system. However Stakeholders also noted it takes time and much effort to break down traditional setting-based approaches to care. This is the challenge for those implementing the Fourth National Mental Health Plan.
There are many barriers to collaboration arising from traditional paradigms of care. The understanding of holistic models of community mental health care differs between sectors and professional groups. The clinical and community models of mental health adopt two distinct approaches that are informed by two fundamentally unique epistemologies. The clinical approach to mental health is focussed on the individual, their symptoms and related treatments. Therefore, the emphasis for a clinician is on diagnosing and treating the pathology. Alternatively, community models recognise the broader impact of social support and networks, education, employment and housing on an individual's capacity to manage and recover from mental illness, while recognising the role played by carers and families in this process. When the clinical and community models function in isolation from one another it is difficult to achieve sustainable recovery for the individual with a mental illness and provide appropriate support for their families and carers. A holistic approach to mental health acknowledges the importance of clinically managing mental illness in partnership with addressing the social, cultural and environmental influences to achieving recovery.
While collaborative practice is reportedly reaping benefits it is in its infancy between the heath sector and community mental health psychosocial services. To improve the quality and extent of collaboration there is a need to develop a sound understanding of what is required as well as the barriers and enablers involved and how change should be supported. Many assumptions which govern existing practice are implicit and have not been surfaced. For example, clinicians are accustomed to referring to another clinician not to a 'service'. Sharing of client information is another issue to be addressed as is the nature of each professional's contribution to client care. Sectors and professions have differing paradigms of practice and systems which reflect those. The rationale for changing practice must be understood and accepted as worthwhile for the both client and the clinician to warrant the effort of change. Therefore governments should consider incentives and the enabling factors for change at all levels for the health and community sector workforce in the design and funding of service arrangements to support desired changes.
For collaboration to be effective governments must use policy and funding levers strategically to change care pathways and practice systems. This requires players to understand the rationale for collaboration, the complementary role other services and professions play, and the types of collaborative practice which would serve clients best
FaHCSIA's strategic role
In terms of FaHCSIA's strategic leadership role in contributing to mental health service system development a range of initiatives to improve the mental health service system operation could be initiated:
- improving the flexibility and efficiency of the system by encouraging pathways of care through cross referrals and collaborations between community and clinical services;
- identifying opportunities to fill gaps in service delivery and accessibility through more flexible use of available resources, for example larger services providing support to smaller services, use of telehealth and phone consultations and use of Internet services;
- developing innovative approaches in collaboration with other sectors to building sustainable services in rural and remote locations;
- sharing the experience of the FaHCSIA Community Mental Health Initiatives to identify what changes are needed and how change can be managed.
Supportive strategies could include:
- ensure that the contribution of all sectors in developing priorities and strategies for the community mental health system;
- legislative changes to remove artificial constraints to seamless service and/or ensure that the community service role is reinforced (for example, the current e-health legislation could be expanded to include community mental health services);
- provision of training to medical professionals in the role of psychosocial services in the care of their clients;
- disseminate examples of effective practice to illustrate the nature and effects of changed practice.
Other system issues
Overall, areas for priority attention in community mental health policy raised during the consultations are:
- increasing mental health literacy in the community;
- increasing awareness and understanding of mental ill-health to support early identification and access to appropriate services;
- working against stigma and discrimination of people affected by mental illness, and promoting their social inclusion;
- providing recovery oriented mental health services which support people with mental illness to have a sense of control over their health and quality of life, including through meaningful occupational and social engagement;
- targeting implementation of evidence-based strategies for populations considered to be most disadvantaged;
- implementing evidence based programs in settings with a strong case for action— these include the home, schools, workplaces and community;
- linking or integrating strategies for promoting mental health and preventing mental ill-health with suicide prevention objectives and programs;
- establishing strategic mechanisms which facilitate coordination of activity across sectors and spheres of government;
- increasing capacity and investment in research and evaluation to support the development of the evidence base (such as indicators for mental health improvement, and economic arguments for the benefits of promotion activities);
- developing coherent national and state implementation planning.
These issues need to be incorporated into FaHCSIA's strategic policy and planning efforts.
While positive outcomes have been achieved from the FaHCSIA community mental health initiatives, the next phase of policy development and implementation will be crucial to their being embedded in the national approaches to mental health, as articulated in the Fourth National Mental Health Plan and in the broader reforms of the health system announced by the Prime Minister in March 2010.
In terms of the development process envisaged under the program logic, while the broad national policy agenda for mental health has been set with a more central role for community services and networks, FaHCSIA needs to pay more attention to the three categories of: influences on policy strategy; service delivery systems; and understanding the needs of target groups.
A key underlying policy influencer is evidence produced by sound research—particularly priority-driven research—designed to inform program development. Significant work needs to be conducted to build a stronger research capacity broadly in social policy and particularly in community based non-clinical mental health approaches. In line with the complexity of client needs capacity-building needs to involve many universities and academic disciplines (including the health and social sciences, economics, statistics, demography, geography and urban studies).
Several examples of successful building of research capacity exist in the health sector with dedicated research funding streams for population health, specific diseases and primary health care. These investments have paid off with improved evidence to inform policy in such diverse areas as reductions in tobacco consumption and cost controls under the Pharmaceutical Benefits Scheme.
The role of peak bodies and the NGO sector in advising on policy approaches and on successful implementation needs to be addressed in the community mental health sector. Currently key roles of peak bodies recognised and utilised include: to undertake research and consultations into key issues in the sector; consult with providers and communities on issues and approaches; and be a vehicle for communication between governments and the community. A large range of peak bodies are concerned with the needs of clients with mental health problems. Concerned peak bodies include not only the mental health sector but other community service bodies, employment, housing, multicultural and Indigenous bodies to name a few. Currently their thinking and effort is fragmented. There is room for more organised approaches to ensure collective cross sectoral input into problem solving on issues such as how CALD and Indigenous communities may be served more effectively, improved approaches to service in rural and remote locations, how early intervention services may be expanded and how carers may be identified and supported.
More collaborative effort between a wider range of peak bodies must be fostered for more comprehensive advice which incorporates the perspectives of a range of sectors as this will be required in mental health system reform.
While the clinical mental health sector has well developed clinical and other professionally focused peak bodies, the community sector's influence is less prominent where the integration between health and community sectors and the needs of targeted population groups is concerned. This is reflected in the overwhelming focus in mental health policy on the clinical health aspects rather than on social factors. If this balance is to be corrected and the policy objectives of COAG and the National Mental Health Plan are to be realised, then strengthening the capacity for peak bodies from the community sector to provide policy inputs will be required.
More broadly, FaHCSIA could establish a forum or other advisory structures bringing together major service providers to identify emerging issues across the sector, assist with assessing the impact of current service arrangements and in devising new funding or service approaches. Many service providers manage a range of community services and can bring broad perspectives to the table as well as detailed knowledge of service system issues.
The third influence on policy is Australian Government and state and territory governments The Australian Government, through FaHCSIA programs, has a major role in social and community policy and similarly states and territories are heavily involved in these areas. However the consultations undertaken as part of the evaluation highlighted that there is little coordination between the two levels of government in community mental health. FaHCSIA could make use of existing health and community services intergovernmental mechanisms to increase its liaison with states and territories. Similarly the need for Australian Government agencies to work more closely and collaboratively in relation to community mental health was widely commented upon. At the Australian Government level, FaHCSIA is best positioned to take the lead on community mental health because of its overall responsibility for the national social inclusion agenda and its range of social, housing and Indigenous programs that go well beyond FaHCSIA's mental health initiatives.
The second tier of the program logic, service delivery systems, also requires national leadership that can be provided by FaHCSIA. As has already been indicated, FaHCSIA has the policy and program mechanisms to coordinate across health, family, youth, homeless and other sectors to focus on community mental health. The three FaHCSIA Mental Health Initiatives are elements of this broader capacity. These have important perspectives to contribute to the redesign of the service system for primary health care, particularly in ensuring that social and economic determinants of health are addressed as part of prevention and early intervention.
Sector engagement
As the lead agency for community mental health initiatives it would be opportune for FaHCSIA to develop a strategy for its engagement in the sector, consistent with the outcomes of earlier consultations, national policy development and the Australian Government's whole-of-government approach. FaHCSIA needs to ensure that the community mental health sector's contribution is maintained and strengthened through the forthcoming health reform processes, particularly in relation to primary care and ageing.
Data collection and planning
Significantly improved data collection and sharing across services is also required. This will include improved record keeping across the community sector and capacity to link social data with clinical health data. GIS allow complex models of population data and service availability and gaps to be identified as an aid to understanding needs better and for planning at quite localised levels.
Research and evaluation
Improved capacity for research and evaluation of approaches are also be required. The broad holistic and community approaches are well founded on studies in Australia and overseas. However, evidence underpinning approaches to greater community-based care in mental health is largely drawn on small-scale studies. Particular service approaches in the Australian context have not generally been rigorously evaluated. Consequently there is not a body of evidence to guide policymakers and service planners in the most effective service approaches and what are the best buys from the range of service models that could be employed.
Sector reform opportunities
The health sector itself is undergoing major reform that presents opportunities for improved coordination across the clinical and community mental health sectors. The Australian Government has announced plans to take full financial responsibility for primary health and aged care and major funding responsibility for public hospitals. These reforms will be accompanied by more local autonomy in the design and delivery of services against national criteria for quality and outcomes. Local networks for hospitals and primary health care will be established by the Australian Government. The three mental health initiatives provide opportunities for improved local and regional collaborations in community mental health. Similarly, planned initiatives in the health sector to introduce shared electronic health records for clinical care (part of the eHealth initiatives) could be expanded to accommodate relevant data from social and community services (currently eHealth approaches are confined to a small set of professions covered by the national health professions registration initiative).
FaHCSIA's leadership role
FaHCSIA can play a significant leadership role in tackling the fundamental differences in understanding between the health and community sectors about what constitutes 'community mental health'. These differences result in divergence about such crucial factors as funding priorities, models of care and funding and location of services. These problems are repeated at the service and provider levels where on-the-ground working relationships are crucial in delivering targeted and effective services that best meet individual clients' needs. In the absence of funding and other incentives, changes to traditional to traditional ways of service are unlikely to occur. Ultimately the policy intent will be frustrated.
FaHCSIA needs to work with other Australian Government agencies (DoHA and DEEWR) to assess current approaches and funding and planning arrangements with a view to:
- developing a shared understanding of the issues in community mental health and agencies' collective and individual responsibilities;
- understanding better what practical barriers can be removed to support local initiatives that lead to improved collaboration in service delivery;
- devising for consideration by government more flexible funding mechanisms that encourage collaboration;
- identifying more flexible funding models to enable the development of suitable and accessible services where traditional models are not serving needs (for example, rural and remote, Indigenous and CALD);
- working with states and territories to improve service delivery synchronisation.
Given its experience and the community mental health initiatives and its broader responsibilities for families, Indigenous people and housing, FaHCSIA could identify innovative solutions to some of the key problems that have arisen from the evaluation. These include how to:
- overcome the limited reach of the current FaHCSIA program in terms of geographical and other access issues and capacity to deal with demand;
- ameliorate some of the funding uncertainty that is a major concern to providers;
- streamline access and reporting rules to reflect better the reality of demand and service patterns;
- address some of the workforce issues that impede recruitment and retention of skilled staff;
- develop data collections that are simple, useful at all levels and can assist in devising more flexible and targeted funding approaches.
A suggested approach for FaHCSIA
A suggested approach for FaHCSIA is as follows:
- Identify the core target populations for FaHCSIA community mental health initiatives. This process should include both identified needs and assessment of unmet need. The social characteristics and geographic spread of the target populations need to be identified.
- Undertake an internal assessment of current and potential contributions across FaHCSIA to the community mental health initiatives, taking account of the population profile, current and projected demand both by type of service and volume, the commitments under the 4th National Mental Health Strategy and the changes for the primary health care sector proposed as part of 'A National Health and Hospitals Network for Australia's Future'.
- Develop a FaHCSIA community mental health strategy. This strategy should address areas such as:
- research: building a community mental health research capacity; undertaking priority driven research; linking research findings to policy and service improvement; identifying service benchmarks and client outcomes and reviewing performance against these;
- peak bodies: supporting the strategic direction for the sector and their engagement in research, policy, service planning and implementation and evaluation;
- governments: leading whole-of-government strategies to encourage greater coordination and collaboration across the social and health sectors;
- In terms of current health reform processes, the Australian Government has committed to take on full funding responsibility for designated primary health care services. A process of consultation with states and territories and the community sector has been foreshadowed to help identify the services that are in scope for the Australian Government-funded sector. FaHCSIA needs to ensure that the providers of community mental health initiatives are identified as within the primary health care arrangements and included in the consultation process. Not only do these services play a proven role in prevention, they also help reduce demand for medical and other clinical services for people with mental health problems, including reduction in hospital attendances and admissions for acute episodes.
In conclusion the FaHCSIA mental health strategy should tackle some of the key impediments to optimal contributions from the community sector to the Fourth National Mental Health Strategy:
- deal with workforce issues, including the need to establish a strategy to develop and support the community health workforce as an appropriately skilled component of the mental health sector with formal training and competency standards;
- deal with the barriers to effective collaboration in the interests of clients across clinical and community services, including better articulation of respective roles and education programs so workers in both sectors can better understand these;
- ensure that the national eHealth agenda takes account of the need to include the community mental health sector in arrangements for appropriately shared patient information;
- ensure that a sustainable funding base for the community sector is based on suitable performance and accountability criteria;
- develop a national data collection for clients and services provided by the community sector to assist in measuring performance and outcomes for clients and planning for future demand.
A key feature of the FaHCSIA approach will need to incorporate a research strategy that will:
- identify service needs for the population at large and for identified groups, including Indigenous people, rural and remote populations, youth, prisoners, people with substance abuse issues and CALD;
- identify best practice both in Australia and internationally for community service models;
- identify flexible and sustainable funding approaches to ensure equity and access as well as efficiency;
- understand better appropriate organisational culture and change management approaches to overcome barriers between clinical and community services.
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11. Recommendations
New approach to models of care
Rather than having separate initiatives covering specific target groups consider a single initiative covering all target groups with services individually or collectively providing a range of supports appropriate to specific client and family needs.
All services should incorporate family approaches in their service structure.
For all initiatives
Postcode and other boundary restrictions should be removed and replaced with appropriate service access guidelines on area. This will allow for service judgment based on the other service structures, the individual situation of applicants and allow a more responsive service. It would also allow services to negotiate with other services to meet needs. Guidelines should place responsibility to report on how much of a service area is supported and what areas are not served.
Review the funding arrangements with a view to enabling more effective service delivery for:
- service travel and staff allocation to support outreach especially where large geographical areas are served;
- staff time required to support collaborative effort at the regional and service levels.
For individual service delivery models
For PHaMs
- relax the eligibility restrictions relating to the timing required for clients to agree to confidentiality and data sharing, allowing the service to make a judgment based on individual circumstances;
- relax the eligibility restrictions for timing for undertakings to address concurrent alcohol and drug morbidity, allowing the service to make judgments based on individual circumstances;
- explore whether the EST should be supplemented with an additional client outcomes monitoring system.
For MHCB
- consider expanding the capacity to support families and children using existing MHCB approaches;
- develop a strategy to take up the outcomes of innovative effort and use services more strategically for service capacity building for prevention and early intervention approaches for young people and families.
For Respite
- replace the term 'respite' with the term 'carer support';
- simplify the service model with an orientation on meeting client (and family) needs;
- support the development of client-centered care approaches by using principles and objectives to guide effort;
- expand the eligibility criteria to encompass young carers in a primary or secondary caring role;
- ensure that carers have access to a suite of support services in a region with expanded access to planned and flexible respite services—these should encompass at least the full range of supports available now;
- encourage innovation by services to support assertive engagement of carers and publicise effective strategies across Australia;
- expand respite delivery outlets so other community-based mental health services— for example, MHCB and PHaMs—can access funding to support carers.
Service system
Regional service planning should be undertaken in consultation with states and territories, providers and regional NGOs with a view to:
- building effective service collaborations, including through inter-service contractual arrangements;
- linking with other FaHCSIA funded services;
- improving the sustainability and capacity of services based on an analysis of the critical requirements for an effectively functioning sustainable service;
- contributing to national collaborative efforts and service pathway development.
Develop a strategy for the building of capacity to meet the needs of targeted groups
This should consider changing the orientation of services to have a family oriented approach, the building of staff capacity and building the capacity of Indigenous and CALD representative groups to work in partnership with mainstream services. This strategy should incorporate attention to effective models which have been developed through existing mental health services.
FaHCSIA—strategic leadership
Develop a strategic policy and plan for community mental health
FaHCSIA should develop a mental health and wellbeing plan to clarify the role of various programs that contribute to mental health and wellbeing and develop policy and service connections to improve the enabling environment and lead to better health outcomes.
The plan should outline appropriate advisory structures involving service provider networks, client groups and peak bodies.
FaHCSIA should use peak bodies as capacity building partners, for example, through a more organised and strategic effort in gaining their assistance for particular target groups and building capacity for them to work collaboratively. A broad suite of interests should be included.
Adopt a strategic approach to workforce development
At the system level identify needs and priorities and policy and system support for an organised approach to workforce development:
- Develop strategies which incorporate attention to building the capacity of the service system to work more collaboratively, especially for cross sectoral and multi-disciplinary collaboration.
- Improve access to inexpensive; accessible timely training nationally with rural and remote area needs a priority. Consider the use of an e-platform or use of existing platforms. Investigate the use of existing courses and resources produced by peak bodies and services for rapid deployment. Explore how existing capacity can be used to support the community mental health system level (for example, the Mental Health Pod).
- Develop assertive approaches to build the capacity of particular groups with Indigenous and CALD workforce a priority.
- Consider leadership development to as a strategy to build mental health sector capacity.
Develop a research strategy to underpin policy and service priorities
Undertake priority driven research to support thinking on policy and service models, particularly for rural and remote areas, and to support contribution to thinking for the development and implementation of the Fourth National Mental Health Plan.
Initial areas for priority driven research include:
- the need for, and approaches to, legislative reform;
- service pathways (for example, the elements of effective referral systems between health and community services and effective partnerships between the community service sector and health);
- roles and needs of services—service capacity needs, develop a clearer understanding of what 'clinical' entails in the service context and how the needs of Indigenous and CALD communities can be better served;
- the strategy should incorporate systematic evaluation of models of care:
- document existing practices and evaluate from a range of perspectives;
- undertake cost benefit studies of recovery models;
- follow up of those who receive interventions, especially to assess the benefits of early intervention, and how that might be followed up at transition points;
- evaluate innovative local approaches as possible models for replication elsewhere, for example, family based services as a means of addressing co-morbidity;
- pay special attention to developing more effective models for rural and remote services where the service environment is less extensive.
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PART C: Appendices
A. Literature review
The purpose of this brief literature and document review is to inform the questions and direction of the evaluation of three mental health initiatives falling within the responsibility of the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA). The three initiatives are Personal Helpers and Mentors (PHaMs), Mental Health Respite (MHR) and Mental Health Community Based (MHCB) Services. These initiatives are part of 19 mental health initiatives resulting from the Council of Australian Governments' (COAG) National Action Plan on Mental Health 2006–2011. FaHCSIA's mental health initiatives were introduced by the Australian Government in 2006 as part of its commitment to increased resources and capacity for the social and community sectors to contribute to the support for persons suffering from mental health problems. These initiatives are targeted at population health and recovery approaches previously neglected at a national level.
The purpose of the evaluation is to inform future policy and practice and the terms of reference for the evaluation have guided the approach to this review. The objectives of this literature review, and its findings, are dealt with under the following key themes:
- the nature and prevalence of mental health problems and the resultant impacts on individuals families and the Australian community resulting in an increasing social and economic burden on society;
- the current policy context and emerging national system and service issues showing the need for additional attention and resourcing to community-based approaches;
- current and emerging service needs for people with mental health problems that require a response from the service system;
- the models of care and best practice in service delivery, where the evidence strongly sustains community-based approaches to mental health care and support as essential components of any effective policy reform;
- issues around the mental health workforce, including availability and possible innovative approaches to making better use of the available workforces;
- approaches to measurement of program outcomes and cost-effectiveness indicating that urgent attention needs to be given to developing suitable measures to assess the impact of recent reforms.
This literature and document review used as a prime source relevant material from literature searches compiled by FaHCSIA's Library. There was also reliance on policy documentation underpinning Australian Government programs, especially the Third National Mental Health Plan 2003–2008 (Commonwealth of Australia 2003) and the National Mental Health Policy 2008 (Commonwealth of Australia 2009a). As a result of these policies, Australian jurisdictions have implemented various initiatives. These are also discussed in the literature review. In addition, there are recent reports from inquiries into mental health services (2008) and into support for carers (2009) by the Senate and the House of Representatives respectively. Where possible, information on overseas literature, principally from New Zealand, the United Kingdom, the United States and Canada, has been included in the review.
Nature and extent of the problem
Mental health is one of Australia's national health priority areas, being one of the more prevalent conditions affecting the Australian population. The 2007 National Survey of Mental Health and Well-being conducted by the Australian Bureau of Statistics (ABS) found that an estimated 3.2 millionAustralians (20 per cent of the population aged between 16 and 85 years) had a mental disorder in the 12 months prior to the survey (ABS 2007). The Burden of Disease report indicated that mental disorders constitute the leading cause of disability burden in Australia, accounting for an estimated 24 per cent of the total years lost due to disability (Australian Institute of Health and Welfare (AIHW) 2008). Major categories of illness include:
- 55 per cent anxiety and depression;
- 10 per cent alcohol dependence;
- 9 per cent personality disorders;
- 8 per cent schizophrenia;
- 5 per cent heroin dependence;
- 4 per cent autism;
- 10 per cent other.
Mental illnesses affect both sexes and all ages. In 2003, females accounted for 53 per cent of the burden attributed to mental illness and males 47 per cent. In females, anxiety and depression were the foremost causes, accounting for 10 per cent of the overall female burden of disease, and ranked third at 4.8 per cent in the overall male burden.
The impacts of mental illness on the community are widespread and it is likely that a significant level of impact is unrecorded. The most visible impact is on the health and community services system. Mental health services are provided in Australia in a variety of ways—from hospitalisation and other residential care, hospital-based outpatient services and community mental health services through to consultations with specialists and General Practitioners (GPs). The individual, social and economic burden is relative to the severity of the condition.
The care is time limited and much of the cost of care accrues to individuals, carers and their families. Many of these costs are hidden and others are not easily quantifiable. Carers, for example, make a significant contribution at much personal cost, including the loss of finances, careers, social connectivity and health problems and being able to pursue personal lifestyle choices. Many of these carers do not self identify with a subsequent loss of entitlements (Commonwealth of Australia 2009). Individuals also suffer loss of education and employment opportunities, stigma and social isolation and are hampered in their efforts to participate fully in Australian society and the economy.
Data on mental health is compiled from a range of sources which are mainly health system oriented, although it does include information from community services offered at a state and territory level. The AIHW (2008) notes there is no standard way of defining mental health-related services and therefore definitions were developed that relate to each data source. It is questioned whether data on community-based mental health services offered by Australian Government departments such as FaHCSIA are captured so it is likely that the picture presented is incomplete.
Current policy context and emerging national system and service issues
There has been considerable policy focus on mental health issues in recent years, including the following:
- The COAG agreed National Action Plan on Mental Health 2006–2011, endorsed in 2006, which injected considerable additional funding into mental health and created COAG Mental Health Working Groups in each state and territory. This placed greater emphasis on whole-of-government approaches and expanded the role of the community sector in supporting persons with mental health issues.
- The Fourth National Mental Health Plan: an agenda for collaborative government action inmental health 2009–2014 was released, building upon the National Mental Health Policy 2008.
- New policies and initiatives in each jurisdiction as part of the implementation of the COAG reforms and the Fourth National Mental Health Plan were formulated.
- The formulation of Senate Standing Committee on Community Affairs, Towards recovery:mental health services in Australia report (2008), which reviewed progress on variousinitiatives and assessed the current state of play of mental health support in Australia.
State and territory governments have been updating their mental health plans to support their agreement to the above policies and supporting agendas.
Key features which arise from the review of the literature include:
- a population health approach;
- socially inclusive, multi-sectoral and whole-of-government approaches to planning and service delivery;
- a focus on 'recovery'— helping people to get on with their lives despite illness;
- stronger engagement with the community in planning and service delivery, including through community-based organisations and carers.
A population health approach
There are a range of psychosocial and environmental determinants of mental health, which translate into risk and protective factors. These include income, employment, education, housing poverty and access to community resources. These determinants and risk and protective factors are acknowledged in the National Action Plan for Promotion, Prevention and Early Intervention for MentalHealth (Australian Government 2000), the National Action Plan on Mental Health 2006–2011 (COAG2006) and the recently released Fourth National Mental Health Plan. The Fourth National Mental Health Plan explicitly adopts a population health framework, acknowledging the psychosocial and environmental determinants of mental health and technology and the importance of mental health issues across the life span from infancy to old age (Australia Government 2009).
A focus on and understanding of the causes, determinants at risk and protective factors affecting mental health has benefits including:
- recognition that most protective and risk factors for mental health lie outside the main domain of mental health services and therefore there is a need for collaborative partnerships with services beyond the mental health domain, across portfolios of government, between levels of government and service sectors;
- highlighting the cost effectiveness and significance of securing shifts in population health and maximising health gain across populations and not just at individual level.
To pursue a population health approach, there needs to be a coherent framework for action that will encompass the range of activities that might be needed to address the range of determinants. That framework needs to describe how the various activities relate to each other. Accordingly, models have been put forward to provide such a framework. The model which the Australian mental health field drew on was that put forward by the Institute of Medicine in the United States in Mrazek and Haggerty (1994) Reducing the risks for Mental Disorders: Frontiers for Preventive Intervention Research. This model was regarded as best portraying the continuum of mental health interventions within a population health framework.
The Australian Government, in its Promotion Prevention and Early Intervention for Mental HealthMonograph 2000, presented the following model adapted from Mrazek and Haggerty (1994).
The monograph defines the terms promotion, prevention and early intervention. Promotion is defined as:
Mental health promotion is any action taken to maximise mental health and wellbeing among populations and individuals (Commonwealth of Australia 2000:4).
Prevention is defined as:
Interventions that occur before the initial onset of the disorder to prevent the development of disorder (Commonwealth of Australia 2000:4).
and early intervention is defined as:
Interventions targeting people displaying the early signs and symptoms of a mental health problem or mental disorder and people developing or experiencing a first episode of mental disorder (Commonwealth of Australia 2000:4).
This promotion prevention and early intervention approach is reflected in not only national policy from the Australian Government but also in the policy of every Australia jurisdiction government. New South Wales, Victoria and the Australian Capital Territory have had explicit promotion prevention and early intervention policies for several years and Western Australia and Tasmania have released explicit policies in 2009. Queensland and South Australia have the concepts implicit in their mental health policy but do not use it as an explicit framework. All state and territory governments are reviewing their policies and plans as part of their commitment to implement the Fourth National Mental Health Plan and a broad consistency is developing.
The Victorian Government appears to be the most advanced jurisdiction in terms of its policy and services based around a prevention approach. It has had a dedicated policy on promotion of mental health articulated since 1999 with its Mental Health Promotion Plan 1999–2002, and then with a further refined framework released in 2005 in A Plan for Action 2005–2007. 10
The Victorian mental health promotion framework draws on health promotion actions that have proven effective in dealing with other health issues, such as tobacco control, healthy eating and physical activity, and include actions such as communication and social marketing campaigns, workforce development, organisational and community development, advocacy, legislative reform and research and evaluation. The framework places particular emphasis on supporting communities and organisations to create environments conducive to mental health and wellbeing. It also recognises that many of the factors influencing mental health lie outside the health system. A key strategy in the framework is the development of effective partnerships between individuals and organisations across sectors and government portfolios. These include those concerned with housing, employment, sport and recreation, education and income security.
Victoria's reform strategy Because Mental Health Matters 2009–2019 puts considerable emphasis on partnerships and shared responsibility. Of particular relevance to this evaluation, the strategy articulates a mental health outcomes framework structured around three domains—health and community outcomes, determinants of mental health and performance of the service system. These three domains provide a useful basis for planning across the various levels of the service system, namely government programs, service and agencies, and community sector services and organisations at the local and, often, regional level. In articulating outcomes, it also provides a basis for monitoring achievements and progress.
10 - This policy framework focuses on three factors demonstrated to have a particular influence on mental health: social inclusion; freedom from discrimination and violence; and access to economic resources such as employment, income and housing.
The Tasmanian Government (Department of Health and Human Services (DHHS) 2009) notes that the 'Spectrum of Interventions' (the spectrum) as originally defined by Mrazek and Haggerty (1994) and subsequently refined by others, is widely recognised and adopted as a population framework for defining the entire range of mental health interventions encompassing promotion, prevention, early intervention, treatment and recovery approaches. The spectrum notes that the Second NationalMental Health Plan of 1998 was the first instance of Australian national policy to adopt the spectrum'sframework and, with some revisions, this continued with the development of the National ActionPlan for Promotion, Prevention and Early Intervention for Mental Health 2000 (Commonwealth ofAustralia 2000a) which has formed the basis of ongoing national and state and territory promotion and prevention implementation and practice.
DHHS (2009) also notes that the various adaptations of the spectrum have reflected increased understanding of the interrelationship between the components of the spectrum and now encompass the role and scope of mental health promotion and concepts such as recovery. The most recent published refinement by Barry and Jenkins (2007) is noted as reflecting a strong health promotion background and further extends the mental health promotion aspect to highlight concepts such as resilience and empowerment.
The Fourth National Mental Health Plan refers in its principles that it is essential to recognise in planning for service delivery the particular needs and challenges of some groups including women, Indigenous Australians and rural and remote communities.
Each Australian jurisdiction has identified groups that are particularly 'at risk' and in most cases relevant to FaHCSIA's three community mental health initiatives. These include Aboriginal and Torres Strait Islander people and Culturally and Linguistically diverse (CALD) groups. Western Australia has a specific policy document covering CALD groups (Western Australia Government 2001) and New South Wales has a policy on Indigenous mental health (New South Wales Government 2007).
Socially inclusive, multi-sectoral and whole-of-government approaches
There is often a stigma attached to mental illness and people with a mental illness very often find themselves excluded from some parts of social life, for example employment, support from their families, proper health care and access to normal community services and activities.
As mentioned above social exclusion resulting from the stigma attached to mental illness has been recognised by the Victorian Government mental health promotion policies and was also highlighted by the work of the United Kingdom Social Exclusion Unit with their publication Mental Health andSocial Exclusion (Office of the Deputy Prime Minister 2004).
A study published by the Australian Government also deals with the impacts of social exclusion in Australia, which can be a downward spiral of unemployment, poverty, family breakdown and deteriorating mental and physical health. All of these impacts can carry great costs to individuals, their families and the country as a whole, both immediately and into the future as the disadvantage becomes intergenerational (Harvey et al 2002).
In an attempt to tackle social inclusion, where the policy aim is to reverse the circumstances, systems and behaviours which lead to social exclusion, the Australian Government established a Social Inclusion Board in 2008. The Board's Principles of Social Inclusion notes that policies can be considered to have been successful when everyone is able to secure a job, access services, connect with family, friends, work, personal interests and the local community, deal with personal crisis and have their voice heard (Australian Government 2008 at www.socialinclusion.gov.au). The Fourth National Mental Health Plan reflects these principles in Priority Area 1: Social inclusion and recovery, which in turn identifies the following national actions:
- improve community and service understanding and attitudes through a sustained and comprehensive national stigma reduction strategy;
- coordinate the health, education and employment sectors to expand supported education, employment and vocational programs which are linked to mental health programs;
- improve coordination between primary care and specialist mental health services in the community to enhance consumer choice and facilitate wrap around service provision;
- adopt a recovery oriented culture within mental health services, underpinned by appropriate values and service models;
- develop integrated programs between mental health support services and housing agencies to provide tailored assistance to people with mental illness and mental health problems living in the community;
- develop integrated approaches between housing, justice, community and aged care sectors to facilitate access to mental health programs for people at risk of homelessness and other forms of disadvantage;
- lead the development of coordinated actions to implement a renewed Aboriginal and Torres Strait Islander Social and Emotional Well Being Framework (Commonwealth of Australia 2009:24).
The research literature further highlights the centrality of homelessness as a factor in (and impact of) social exclusion. For example, the New South Wales Government Housing and Accommodation Support Initiative (HASI), a partnership program funded under Partnership Against Homelessness (PAH)11, brings together 12 New south Wales Government agencies that fund or administer programs for homeless people. Furthermore, the New South Wales Community Mental HealthStrategy 2007–2012: from prevention and early intervention to recovery, promotes strategies for secureaccommodation, community participation, education employment and good physical health and the role that all of these play in good mental health (New South Wales Department of Health 2008).
The South Australian Government has used the concept of social inclusion as the guiding framework for reforming mental health services in South Australia. Stepping Up: a social inclusion action plan for mental health reform 2007–2012 (South Australia Social Inclusion Board 2006) aims to be peoplecentered and recovery-oriented and spells out seven major areas for reform and implementation:
- developing a people centered system; understanding the people who use the mental health system; implementing a stepped system of care with community services at its centre; developing a workforce for the future; focusing on prevention and early intervention; redeveloping Glenside SA as a centre for state-wide specialist services; encouraging agencies to work together; and tackling stigma and discrimination.
11 - Is a successful partnership program between New South Wales Health, the Department of Housing and, at the local level, Area Health Services, Area Mental Health Services and Non-Government Organisations (NGOs).
Recovery oriented approaches
During the 1990s considerable research in dealing with mental illness built an evidence base that showed recovery from mental illness does occur, that social inclusion aids recovery while social exclusion impedes it, and the attitudes of other people strongly influence how well people recover.
Australian policy has drawn upon several commentators with regard to recovery approaches such as Deegan (1988) and Anthony (1993). Deegan (1988, p. 11) defines recovery as a way of life in approaching the day's challenges, recognising that it is not a perfectly linear process:
The need is to meet the challenge of the disability and to re-establish a new and valued sense of integrity and purpose within and beyond the limits of the disability; the aspiration is to live, work and love in a community in which one makes a significant contribution.
Similarly, Anthony (1993, p. 527) describes recovery as aspirational, changing one's personal attitudes, feelings, goals, skills and even roles:
It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness.
Research by the Mental Health Coordinating Council (MHCC) (2007 p. 6) contains a list of the basic components of a recovery framework as follows:
- individualised, strengths-based approach to care, respecting each person's expertise in and capacity to manage their own health;
- whole-person focus, not just symptoms;
- self direction — consumer and family have direct and ongoing input into interventions;
- trust — someone to be there at times of need;
- hope;
- individual responsibility;
- recovery can occur even when symptoms reoccur;
- recovery is often episodic, not necessarily linear;
- recovery is both a process and an outcome.
These components are reflected in the policy of the Australian Government and most state and territory governments with concern for consumer and carer participation and empowerment to: determine early warning signs of illness; establish partnerships between consumers, carers and service providers; call for a change of relationship with clinicians and treatments providers; and identify risk and protective factors at individual level as part of the recovery process.
The Fourth National Mental Health Plan has social inclusion and recovery as its priority area 1 and has a specific action to:
adopt a recovery oriented culture within the mental health services, underpinned by appropriate values and service models.
The plan also includes 'services delivered with a commitment to a recovery approach' as an underlying principle (Commonwealth of Australia 2004:10).
Community engagement: the role of community-based services and carers
The literature, from Australia and internationally, shows that being supported in the community improves the quality of life and chance of improving capacity to participate in society for people with a mental illness. Carling (1995) identifies six steps for social integration:
- increase consumer opportunities for social relationships;
- increase support for social integration;
- increase diversity of social connections;
- improve continuity of relationships;
- expand the number of freely given relationships; and
- increase chances for intimacy.
However, people with a mental illness cannot take these steps without preparation and support. Importantly, community-based organisations are well placed to provide such support, including those funded under PHaMs in treating the consequences of mental illness. Evidence from studies in Australia shows that the community sector is effective in its delivery of care and support services (Penrose-Wall and Bateman 2006). Furthermore, all Australian jurisdiction policies have implicit in them community sector NGOs as a major component of the delivery system.
South Australia's stepped system approach of mental health reform places community mental health services at the centre of the system thereby becoming the 'cog' driving the system. It places responsibility on community health services for managing partnerships with primary health care, private specialists and government and non-government sector. In proposing some changes to the structures and functions of existing community mental health teams the stepped system approach gives responsibility to the community mental health services for:
- leading an integrated model of rehabilitation and recovery;
- preventing escalation through people being managed in the least restrictive, most appropriate and cost effective options;
- facilitating integration across community and bed-based services;
- ensuring continuity of care between the community, hospital and between the stepped levels of care;
- managing appropriate shared care arrangements between primary mental health care and the specialist system;
- holding and managing funds freed up through the implementation of the reform process (South Australian Social Inclusion Board 2007 p. 34).
Of particular interest with the stepped system approach is that the state and territory government's funded community mental health service has responsibility for coordinating the patient support and adopting the partnership leading role that is essential to underpin social inclusion and recovery approaches. Another example of this is the role mental health clinical care coordinators play in New South Wales Area Health services.
The importance of carers in supporting effective mental health services is well documented (Commonwealth of Australia 2009) and accepted in various national policies and plans. However, there is also extensive documentation of the adverse health, social and financial outcomes for carers. Cummins et al (2007, pp. v–vii) surveyed around 4,000 carers using validated measurement indexes and found key areas for concern, including:
- significantly lower wellbeing for carers than for the population as a whole;
- increased levels of physical pain exacerbated by reduced access to health services;
- lower than normal household incomes, with high levels of difficulty in meeting the costs of food, housing, utilities and other essentials;
- reduced leisure time;
- increased stress related to all of the above, and difficulties in ensuring access to appropriate services for those being cared for.
There are a wide variety of models of care in the mental health field, particularly regarding services provided by community-based organisations, NGOs (those independent of government that may or may not receive government funding). NGOs are often involved in what are broadly termed community-based, recovery-support services. These may be clinical or non-clinical in nature, or a combination of both. Depending on the context they can cooperate with, partner with, or collaborate with, services already provided by government. Whatever the model, carers can play an important part in the support and recovery of people with mental health problems.
The National Mental Health policy recognises the importance of supporting carers in their roles:
The crucial role of carers in prevention, early intervention, treatment and recovery will be acknowledged and respected and provided with appropriate support to enable them to fulfill their role (Commonwealth of Australia 2009a, p.21).
In 2009, the House of Representatives Standing Committee on Family, Community, Housing and Youth (the Committee) inquired into better support for carers and examined issues facing the sector. The report is lengthy and included 50 recommendations relating to:
- identifying demand, demographics and available supports and services;
- the need for a national and strategic approach to carer recognition and policy;
- information, skills and capacity building;
- financial assistance;
- access to supports and services;
- employment and education;
- health and wellbeing (Parliament of the Commonwealth of Australia 2009).
The Committee further identified the following major themes:
- lack of recognition of the role and contribution that carers make to society and the absence of a national strategic approach to supporting carers and their families;
- difficulties in accessing necessary and relevant information on the support and services available to carers, and lack of assistance for carers to develop the range of skills needed to support them in their caring role;
- financial stresses facing many carers and their families as a consequence of opportunity costs, the level of government financial assistance and the additional costs of disability and caring;
- difficulties with community care systems—specifically, the evidence highlighted significant concern in relation to the complexity of systems, the level of unmet need, the costs of accessing services, inflexible delivery of services and, in some cases, the questionable quality of care;
- lack of choice for carers in relation to participation in the workforce and/or education, primarily due to shortages of respite or alternative care options for the care receiver and inflexible working practices;
- the physical, emotional and social impacts of caring on the health and wellbeing of carers and families (Parliament of the Commonwealth of Australia 2009 pp. 12–13).
The Committee concluded that the evidence presented a:
'compelling need for significant and fundamental reforms to the system of supports and services for carers and care receivers' (Parliament of the Commonwealth of Australia 2009 p.:14).
In particular, the Committee endorsed the approaches of person-centered care that provide more flexible and tailored care programs delivered through NGOs in the community. In the Committee's view these approaches would improve significantly the capacity of carers to be involved in support roles with enhanced outcomes for clients
Current and emerging service needs for people with mental health problems
The most recent and comprehensive review of the status of mental health services in Australia has been provided by the Senate Standing Committee on Community Affairs (SCCA) in its September 2008 Report: Towards recovery: mental health services in Australia (Commonwealth of Australia 2008).
The SCCA welcomed COAG and related reforms, including the significant funding boost for mental health. It noted the following key positive outcomes resulting from the National Action Plan onMental Health:
- improved access to previously under-utilised members of the mental health workforce, including psychologists and other allied health providers;
- access to new funding for many NGOs to help provide a range of community-based supports;
- the establishment of programs that try and reach people who have not been receiving services because of the patchy nature of the system.
However, the SCCA concluded that a lot more needs to be done, describing efforts to improve mental health services as a 'work in progress'. The SCCA identifies the following key areas where sufficient progress has not yet been made:
- the National Mental Health Plan does not set out a vision for mental health services in Australia and care still varies markedly between the states and territories;
- consumers have not been given a priority voice in formulating policy and implementing programs because of insufficient resources for resources and capacity building for consumer groups;
- mental health services are unevenly distributed and remain heavily dependent on the availability of the workforce, with particular problems of access outside of major cities and in parts of these cities;
- some groups of people, including those with the most complex needs, are not getting the kinds of services they need due to cost or excessive demand for existing services;
- stigmatisation of people with mental health remains a problem with too many cases of poor treatment and abuse;
- the additional funding for mental health services has predominantly gone to generic services with insufficient attention to special groups such as Indigenous, CALD, youth, aged, people in prison and people living in rural and remote areas;
- serious shortfalls remain in access to affordable housing and employment services for many people and these are necessary fundamentals of a population health and recovery approach;
- consumers remain critical of the lack of coordination between levels of government;
- workforce shortages around Australia continue to affect the provision of mental health services;
- minimal attention has been given to evaluation and outcome measurement of new mental health initiatives, with no way of knowing whether funds are being invested in the most effective ways.
Some issues identified in various inquiries have not been addressed in any current policy reforms. One is the need for services for those who have a problem (for example, not an illness). Another is the needs of families affected by mental health, (for example, siblings, grandmothers and adults and children in caring roles).
Components and underpinnings for effective reform
Person centered care and integrated approaches
Evidence is now emerging that addressing adverse developmental health outcomes will require comprehensive strategies and holistic approaches which empower individuals to overcome problems associated with socio-economic determinants of heath and wellbeing and also problems relating to personal and social factors.
There is an extensive evidence base on person centered approaches to caring in the context of community participation. A review of this evidence was undertaken on behalf of the New South Wales Government in 2008 (van Dam et al, 2008) and provides guidance to systems or organisations that intend to embark on person centered approaches to care and carers support. This literature review concluded that 'person centered approaches can achieve significant outcomes for individuals with disability' (van Dam et al, 2008, p3) and 'positive outcomes have been evident through large scale studies, small studies and individual reports' (van Dam et al, 2008, p. 34).
Person centered approaches have been endorsed by governments. However, the literature review also highlighted implications in adopting such approaches in that person centered models require a high degree of flexibility ultimately with the goal being to provide care plans tailored to individual needs. There would be a crucial role for community-based NGOs to coordinate the various support and care services individuals require. Much more collaboration across the sector would be needed.
There is also emerging evidence to suggest that integrated services such as family programs can operationalise support for families at all levels of influence. These linkages could operate on many levels:
- principle linkages (conceptual and philosophical / shared objectives and target groups);
- organisational linkages (such as partnerships, staff responsibilities, sharing resources);
- practical on-the-ground linkages (such as cross referrals linked through case management processes).
Many innovative pilot programs now implement multi-component interventions that focus on reducing various risk factors in areas such as family, schools and peer environments. These appear promising in reducing risk and strengthening pro-social behavior (Watt 1999 p. 299). In particular, programs using multiple interventions work better than those using a single intervention (Watt 1999).
Treatment models that address many aspects of people's lives—multiple interventions—also need to work with all systems impinging on families' lives (Dawe Fry et al 2007; Watt 1999). For children of substance abusing parents, these could include interventions such as playgroups and support groups for mothers as part of a strategy to reduce social isolation and improve coping strategies.
There is also a growing body of evidence to support the capacity of family therapy to engage and retain clients in therapy and its efficacy in ameliorating adolescent drug use as compared with other approaches (Liddle and Dakof 1995a).
Specific family therapy approaches—such as Brief Strategic Family Therapy (Szapocznik and Williams 2000) and Multidimensional Family Therapy (Liddle et al 2001)—have shown great promise in terms of reducing drug usage in adolescents and improving family functioning.
Despite many examples of innovative and effective practice in Australia and internationally, none have been evaluated for outcomes. Therefore empirical evidence to inform practice is limited. Clearly more research is needed on effective models and service interventions across all fields. Research, in particular, needs to systematically explore variables in service components (Kumpher and Alexander et al 1998; Scottish Executive 2006; Dawe and Fry et al 2007).
Recovery approaches
Recovery approaches are key components of the national mental health policies and strategies. A commonly used definition of recovery (Anthony 1993 p. 527) is that it is:
a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills and roles. It is a way of living a satisfying, hopeful and contributing life, even with the limitations caused by illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness...
The Shepherd et al (2008) contends that 'recovery' is an idea whose time has come. Its main impetus came from the consumer/survivor movement in the 1989s and 1990s and was based on self-help, empowerment and advocacy. Shepherd et al (2008) note that recovery has become the key organising principle underlying mental health services in New Zealand (New Zealand Mental Health Commission (NZMHC) 1998), the United States (DHHS 2003), Australia (Commonwealth of Australia 2003), Ireland (Irish Mental Health Commission, 2005) and Scotland (Scottish Executive 2006). In England the ideas behind recovery are also supported by various United Kingdom Department of Health policies that aim to promote self-management of long-term conditions and 'choice' (Shepherd et al 2008). In Canada a Senate Committee reported in 2006 on mental health delivery in Canada. It articulated a vision of a transformed mental health system and indicated that 'at the core of this vision is a recovery-oriented, primarily community-based, integrated continuum of care' (Parliament of Canada 2006).
The Mental Health Council of Australia (MHCA) (2006) points out that while no one single service model can do everything, some common features, values and principles are useful. The MHCA indicates that an effective community-supported recovery service will:
- involve partnerships between consumers: family and/or carers; NGOs, private and government providers; and community-based and clinical services;
- address needs holistically;
- avoid silo approaches and thinking;
- have prevention and early intervention approaches at its core;
- reflect a spectrum of care and offer a range of intensive support options;
- build and foster community understanding and engagement with and around the person;
- leave systemic issues to be handled by the system and providers, not consumers;
- support autonomy, independence and freedom of choice while the person is actively engaged in their treatment and support options;
- incorporate a range of paid roles that are not clinical, such as system advocates and peer support;
- treat the person with the same human rights as anyone else.
An effective community-supported recovery service would be built on effective action in relation to partnerships (discussed in a separate section of this literature review), prevention and early intervention and freedom of choice. Prevention and early intervention are features of the Australian Government's Promotion, Prevention and Early Intervention for Mental Health (Commonwealth of Australia 2000). This provided the theoretical and conceptual framework and background for Australia's National Action Plan for Promotion, Prevention and Early Intervention for Mental Health 2000 (Commonwealth of Australia 2000a), described by DHHS 2009 as continuing to be recognised as a relevant and contemporary framework for guiding population-based approaches.
Prevention is defined as 'interventions that occur before the initial onset of a disorder' and they are designed to prevent a disorder from developing (Commonwealth of Australia 2000 citing Mrazek and Haggerty 1994). Early interventions refer to those targeting people displaying the early signs and symptoms of a mental health problem or mental disorder and people developing or experiencing a first episode of mental disorder (Commonwealth of Australia 2000).Warner et al (2006) notes that:
the literature makes it abundantly clear that service users want to be offered more than just medication: they want access to talking therapies, services which take account of their gender, culture and ethnicity, and self-management programs which are oriented towards recovery... Unsurprisingly, service users need information and support to help them make informed choices.
The NZMHC (1998) was more explicit. It argued that recovery could never take place in an environment where power was used to coerce people and deny them choices. In a paper on choice in mental health, the United Kingdom Institute for Public Policy Research (IPPR 2005) defined choice as the power to make decisions, noting that the inevitable logic of choice is to re-direct power to citizens. IPPR commented that in the past mental health services have been one of the most disempowering areas of public services, where people had few options and little control over finding better mental health.
Consistent with the above, the MHCA (2006) notes that the values and principles that must underpin community-supported recovery include:
- putting the needs and rights of consumers first;
- addressing and acknowledging the needs and rights of close family members;
- providing locally-based flexible community support services that consider the needs of all social and cultural groups within that community;
- ensuring collaboration between non-government community-based services and clinical services;
- respecting privacy and confidentiality of consumers, as defined by consumers and acknowledged by providers and carers;
- ensuring services are driven by consumer involvement in decision making, planning and evaluation;
- developing proactive strategies to gain acceptance within the community as valued members of society;
- designing services that help eliminate the stigma associated with mental illness.
A recovery orientation in mental health has clear workforce implications. The NZMHC (2001) produced a set of recovery competencies for workers, stating that a competent mental health worker:
- understands recovery principles;
- recognises and supports the personal resourcefulness of people with mental illness;
- accommodates diverse views of mental illness, treatments, services and recovery;
- understands discrimination and social exclusion, its impact on people who use services and how to reduce it;
- acknowledges the different cultures and how to work with them;
- has comprehensive knowledge of community services and resources and actively supports people who use services to use them;
- has knowledge of the 'service user' movement and is able to support its participation;
- has knowledge of family perspectives and is able to support their family participation.
Community based models
DHHS (2009) in their review of Australian and international mental health promotion identifies the five platforms and associated strategies of the Ottawa Charter for Health Promotion (World Health Organization (WHO) 1986). The fifth platform points to reorienting services toward promotion, prevention and early intervention. DHHS (2009) further notes that the concept of recovery for people with mental illness is closely aligned with mental health promotion. DHHS (2009) summarises selected Australian and state and territory policy documents in relation to scope, policy drivers, approaches (in terms of: targeted population, determinants or inclusive approaches), and priority populations. The report also presents a discussion of international policy development, approaches and models for the United Kingdom (England, Scotland and Wales), as well as New Zealand, Canada and the United States. It also noted that other countries in Europe (including Denmark and Italy) and in Asia (including Thailand) are active in this area.
In Australia, the 2006 COAG National Action Plan on Mental Health was accompanied by significant funding for community-based mental health services delivered through NGOs (COAG 2006). In October that year the MHCA reflected on innovative models of mental health in Australia and overseas, identifying 21 innovative models in Australia, New Zealand and in Italy and Canada. It concluded that:
...'no single service model of community-supported recovery will meet the needs of all people living with a mental illness and who from time to time require very high levels of support' (MHCA 2006).
In particular, the MHCA (2006) made reference to the following points from Queensland research and New Zealand's Community Living Service model that:
- non-government services play a vital role in supporting people through recovery and in building sustainable support systems for consumers, their families and natural supports;
- successful services demonstrate some common characteristics and features including strong partnerships;
- between NGOs and other mental health services and good access to acute and sub-acute services as part of the recovery process for people at crucial points in their lives. This in turn demonstrates that partnerships and collaborative models are essential;
- because several of the models examined are managed by national NGOs, such as the Richmond Fellowship and the Canadian 12 model, positive opportunities exist for national leadership and comparative assessments across jurisdictions.
The MHCA (2006) presents information sourced from the Association of Relatives and Friends of the Mentally Ill (ARAFMI) Queensland and Queensland Health (2004) summarising various models of support in Australia, Canada, Italy, New Zealand, United Kingdom and the United States. That literature recommends providing:
- short-term support in the home — which is flexible to meet the needs of the consumer;
- respite support offered in a flexible way to preserve the family unit and facilitate the consumer's recovery-oriented goals;
- safe house support — a crisis service that is an alternative to hospital;
- phone support — to receive immediate emotional support from a person with an understanding of mental illness;
- crisis outreach support — a team of people able to respond immediately to a crisis;
- brokerage support — money that can be used flexibly according to consumer need;
- host family schemes — which enable a consumer to spend time with a family or household members who provide accommodation, meals and informal support;
- transitional housing — where the consumer can recover from an illness or crisis and develop the skills necessary to re-integrate with the community;
- peer support — from people with personal experience of mental illness and who can share that experience to help support others;
- carer mentor support — provided by carers with personal experience who can share theirs experience with others;
- individual long-term recurrent support packages — to fund consumers for as long as is required.
12 - The Canadian Mental Health Association (CMHA) provides a range of services in 135 communities across Canada. According to MHCA 2006, the CMHA's framework puts the consumer at the centre while maintaining programs with a national reach. For example, it runs a Community Outreach Service aimed at keeping people in their homes and out of hospital.
MHCA (2006) also notes that, as with the Queensland ARAFMI project (already referenced), the models examined for its study 'reinforce the theme of flexibility to enable a purchaser to buy a suite of services'. Peer-based support was seen as a strength of many models, as was good access to crisis teams. Collaboration was highlighted in every model including with other providers, clinical services, and with families and natural supports.
While it was noted earlier that the United States has no available national policy for mental health (DHHS 2009), this has not prevented action at a state and territory level. For example, Koyanagi et al (2008) note that five states and territories have self-directed care programs in place for adults with serious mental illness, with pilot projects in two further states and territories. Self-directed care allows consumers to manage their own care and control a budget to pay for their services and supports. In this task, they are assisted by counsellors, brokers or facilitators, who are often peers.
A study by Alakeson (2007) found that self-direction was shown to improve consumer satisfaction with services compared to traditional community mental health services. In interviews, consumers attributed this to a number of features of self-direction such as: the focus on recovery rather than symptoms; its flexibility in meeting individual needs; and the support provided by counsellors and peers in articulating goals and developing spending plans. Furthermore, early evidence indicates that participants in self-directed care have been shown to make less use of crisis stabilisation units and crisis support and greater use of routine care and supported employment than non-participants in the traditional community mental health system.
However, it should also be noted that self-directed care is not a new phenomenon and has existed in various forms since the 1950s (Brown et al 2008). The consumer/survivor/ex-patient (c/s/x) movement is one (Adame and Leitner 2008), and there is a network of self-help centres operated by consumers in New Jersey (Swarbrick 2007), both embodying notions of peer support, empowerment and recovery.
The increasing focus on the consumer or purchaser has also attracted debate elsewhere. In the United Kingdom, a paper from the IPPR (Rankin 2005) made two recommendations, also closely linked with the concepts of empowerment and choice. The two recommendations are that:
- the GP should no longer be the sole gatekeeper into services—mental health support should be accessible through different types of workers based in community organisations; and
- people should be entrusted with their own personal recovery budgets, adapted from the current practice of direct payments.
However, Dickinson and Glasby (2008) sound a cautionary note. They refer to personalised care currently appearing to be 'a cornerstone of the [United Kingdom] Government's policy to transform public services.' The authors argue that 'personalisation negates the need for health and social care agencies to work in partnership' and that 'this interface is more imperative than ever' (Dickinson and Glasby 2008).
Partnerships and collaboration
Many parties, at various levels, need to work together to provide coherent action in meeting mental health needs. The Fourth National Mental Health Plan outlines a whole-of-government approach to population health, noting that there are also important players beyond, as well as within, the mental health sector. In an attachment entitled 'A partnership approach', the plan articulates the scope for partnerships and 'a strategic, coordinated and collaborative approach' between Australian Government and state and territory government portfolios within and outside health (for example, employment, housing and education) in improving mental health outcomes.
The need for effective partnership and collaboration is heightened where services are delivered to co-morbid clients. MHCA (2009) found that the literature on co-morbidity of substance use and mental disorders indicates that an integrated care approach needs to be taken to achieve positive outcomes for co-morbid clients. Better collaboration between services and integration of social and other support services for the benefit of the individual makes a real difference. This is especially so where specialist services are limited, in rural and remote locations.
In his recent report on people with mental health problems or learning disabilities in the British criminal justice system, Bradley (2009) indicated that ultimately partnerships at the regional and local level were central to the delivery of this reform agenda. He noted that 'where they have worked best, they have been locally structured and locally determined to reflect local circumstances.'
In an Australian community-based shared mental health care context, Keleher (2006, p. 92) discusses a 'partnership continuum' 13 which describes the degree of intensity and engagement between partner professionals. Collaborative practice 14 is ranked second only to integrated service delivery in the seven-level continuum.
At a departmental level in New Zealand, Pakura (2004) emphasises the 'vital necessity' of collaboration within an agency, particularly in Indigenous mental health. Pakura (2004) indicates that inter-sectoral collaboration suggests a number of key factors are required for success:
- a defined practice model that promotes cohesive planning;
- a lead agency that provides training support to workers;
- appropriate people who can make commitments, attend meetings and participate collaboratively;
- a team that identifies and develops whānau; family specific supports based on real needs;
- whānau that drives decision making (as opposed to fiscal constraints).
13 - In ascending order of intensity, the continuum identifies and describes seven levels: isolation; networking; communication; cooperation; coordination; collaborative practice; and integrated service delivery.
14 - Collaborative practice is described as: 'longer-term and more deliberate efforts of organisations and groups to undertake shared planning and take joint responsibility and with equal commitment, for joint activities and shared vision of the outcomes, with high level of trust and power sharing based on knowledge and expertise.'
At a clinical professional level, Keleher (2006) notes that features of collaborations such as inter-disciplinary trust, working together, shared planning or sharing of resources, are weak in community-based shared mental care15 in Victoria, suggesting that 'current practice models are working at a level of cooperation rather than true collaboration.' A study by Gartrell and Keleher (2005) concluded that shared care was primarily used by GPs as a model for referral, with little networking and only weak levels of information sharing. The researchers further commented that consumers 'are seeking multifaceted solutions that are not solely medically based'. From a broader perspective, the MHCA (2006) noted that:
Partnerships between non-government, clinical, community-based, and hospital-based services are crucial for some people as no single service can ever guarantee that it can prevent acute episodes of mental illness. As such, access to acute and sub-acute services being part of a collaborative approach is critical, not just for consumers but also for community-based providers be they NGOs, government, clinical and non-clinical providers. Importantly, it would be impossible to sustain some NGO services if access to good clinical, acute and sub-acute services was unavailable. Partnerships are also critical given Australia's multi-layered government system and the public–private service mix.
The Australian Government Senate and Parliamentary inquiries found that the need for collaboration across the mental health sector within governments, between governments and NGOs should be a high priority (Commonwealth of Australia 2008; Commonwealth of Australia 2009).
In a practical example, Patterson (2005) discusses the experience of the Eyre Regional Health Service in South Australia, noting the challenges faced providing a comprehensive service in a rural and remote setting. Various types of clinical and non-clinical partnerships have been established—in some cases purchased and in other cases through memoranda of understanding and service agreements. These have greatly facilitated collaborative program design and delivery. In fact, 'partnership is seen to be fundamental to effective and efficient health service delivery'.
However, one impediment to the establishment of partnerships noted by Patterson is the short-term nature of funding:
The duration of funding needs due consideration too, with capacity to build services being limited when contracts are relatively short.
Family interventions to address needs associated with substance misuse
There is reasonable agreement in the literature across the mental health, health and child protection fields to suggest that family interventions should form a significant part of the response to mental health and substance abuse issues (Kumpher 1999 NHMRC 2001). There is also evidence that dealing with any of these issues alone is relatively ineffective in improving outcomes in view of the complex factors which lead to drug misuse. This evidence is consistent with the research on health and wellbeing that maintains that the effects of clinical intervention are limited and the socioeconomic influences on health and wellbeing must be addressed for sustainable improvements to occur.
Action includes attention to structural factors such as poverty, housing, and education. Policies must also address factors such as social isolation and personal empowerment, through factors such as education levels and the generation of safe and supportive living environments (WHO 2007).
In addition, strong family relationships are a crucial factor in developing an individual's resilience in the face of adversity (Australian Institute of Family Studies 2007) and strengthening families to deal with adversity is an integral part of preventing problems and resolving them.
15 - Shared care is described as a term used loosely to describe a range of community-based practice primary care models in mental health care focused on increasing access to specialist mental health services through cooperation with primary care providers, particularly GPs. (Keleher 2008 p. 90).
Workforce issues
Examination of the literature including policy frameworks, evaluations and consultations consistently raised the development and maintenance of workforce supply and quality as a high priority issue. Workforce development is essential for sector capacity development and sustainability and the provision of quality services. However, effort is reported to be piecemeal, fragmented and unsustainable.
There are compelling reasons to expand the parameters of workforce planning and action to support interventions along the population health spectrum. These include the high cost of the impacts of mental health and the emerging evidence of effectiveness of community and family-based approaches in ameliorating problems and acting effectively as primary prevention in the family setting.
Workforce development has been conceived historically by many as focusing on the needs of training and development strategies for the individual worker instead of as a supporting strategy to enable effective implementation of programs. Therefore, to be effective workforce development must act at a number of levels as identified by the National Research Centre on Alcohol and other Drugs (NCETA 2001). These include strategic systems level, organisational levels and team/individual levels.
Strategic systems level
For changes to succeed in the mental health service delivery system, action on systems and structures and an emphasis on collaboration underpinning service delivery are imperative.
The strategic level should also encompass needs Australia wide and include the perspective of all jurisdictions. Current approaches are inadequate to address changes in the way professionals are expected to practice and to the way pathways of care can include the integration of prevention approaches. They are also inadequate to respond to difficulties in supply and retention and to deal with issues such as demand surges. These difficulties can be based on a range of factors such as emerging programs (for example FaHCSIA's community mental health initiatives) and mining booms which can drain the workforce for higher remuneration and new policy. Strategic level action must therefore include:
- addressing the key factors which affect supply and retention of the workforce to all sectors such as salary and conditions;
- building innovation and developing evidence to support workforce development in mental health;
- developing and implementing strategies to transfer innovation and research to practice;
- upgrading the training delivery system for professional development to provide a suite of essential training as a minimum, including cross sectoral development;
- developing the ability of different professional groups and different sectors to be contribute to prevention and recovery;
- improving the access to professional development by supporting e-learning and delivery which would provide a basis for high quality, sustainable and available training, as needed;
- developing and implementing a strategy for rural and remote areas for improving supply and retention (including through, for example, scholarships, marketing, incentives to stay, career pathways, regional recruitment);
- developing the workforce so underserved groups are supported, for example, Indigenous and CALD groups.
Organisational level and team level actions are influenced by the infrastructure, strategies and funding available to support workforce development. Action at this level includes:
- establishing and implementing workforce development policies;
- providing supervision and mentoring programs;
- providing professional development opportunities as needed;
- offering adequate rewards and recognition;
- negotiating job redesign and job enrichment with workers;
- providing a healthy, safe and pleasant working environment;
- participating in and supporting workforce development programs and research.
Actions at the team level include:
- identifying professional development needs and priorities;
- proactively developing mentoring relationships;
- providing support, guidance and encouragement to colleagues;
- fostering openness to change and excellence and responsiveness in work practices;
- implementing shared care arrangements;
- developing professional/collegial networks;
- developing innovative rewards.
Effective changes in local service delivery strategies constitute system changes which require a commensurate shift in the skill sets and mind sets of all workers (Foster-Fishman and Behrens 2007). These mindsets maintain and constrain the status quo and are recognised as a major barrier to the inclusion of family and community strategies with traditional mental health services. Because the fields of mental health treatment and family therapy utilise similar professional staff it is assumed that workers with similar qualifications, such as psychology or social work, can work with equal skill across both fields. This has proven not to be the case (National Guideline Clearinghouse at http://www.guideline.gov).
The literature regarding the blending of mental health with community and family service approaches illustrates the divergent approaches and philosophies. It also reinforces long-term service frameworks and practices which prevent the effective integration of treatment across the service spectrum and therefore undermines the development of effective care pathways for clients. The following quote referring to substance abuse treatment is equally applicable to the mental health field:
The fields of substance abuse treatment and family therapy share many common assumptions, approaches, and techniques, but differ in significant philosophical and practical ways that affect treatment approaches and goals. Further, within each discipline, theory and practice differ (National Guideline Clearinghouse at (http://www.guideline.gov)
The literature and national and jurisdictional policies support the development of integration of effort by improving the understanding of staff of the interrelationship between service types. Traditional practices and structures detract from the ability to harness the different service sectors effectively. Mental health treatment professionals have developed specialised knowledge of addiction and recovery. Their goal is individual client recovery and such issues as family pressures that threaten attainment of that goal should not be allowed to distract the client. Family therapy practitioners conversely take ecological or systems approaches, seek to work with multiple family members and the communities of which they are a part. Multi-systemic approaches require an understanding of a range of disciplines and treatment philosophies. More integrated approaches would be instrumental in enabling sector collaboration and providing better services for families dealing with multiple and complex problems.
It is clear that an adequate, quality workforce supply is a continuing challenge which greatly undermines the capacity of the system to work optimally. The literature and a range of program evaluations confirm that there are capacity and strategy gaps affecting all levels of capacity.
Peer support workers
A peer support worker is defined as 'someone who is living well with a mental illness and who has been engaged to share their experience to assist and support other people with a mental illness' (Nestor and Akins 2006). Descriptions and roles vary, but peer support workers are often employed in a paid or voluntary capacity in self-help and consumer-led organisations. While consumer-led organisations are 'few' in Australia (Commonwealth of Australia 2008 p. 175) they are more common in North America, including, for example, those established as part of the consumer/survivor/ex-patient movement in the United States and Canada (Adame and Leitner 2008).
In an early North American study based on limited data, Davidson et al (1999) conclude that mutual support groups may improve symptoms, provide larger social networks and enhance quality of life. However, their impact was limited at the time by low utilisation and high attrition rates. A recent Canadian Parliamentary report (Parliament of Canada 2006) noted that, historically, self-help volunteer organisations have not received formal funding. Paid peer support 'has emerged in isolated pockets supported by provincial/territorial funding'. The Canadian Senate Committee recommended that funding be made available and targeted at increasing the number of paid peer support workers in community-based mental health service organisations, and providing stable funding to strengthen existing and establish new peer development initiatives (Parliament of Canada 2006 p. 237).
However, the literature does not shed light on the relative merits of voluntary versus paid peer support work. However, a small South Australian survey of Peer Specialists by Nestor and Akins (2006) found that being paid as a peer worker:
validates the work and is financially empowering with positive effects on health, leisure, quality of life and the ability to participate in community life.It provides relief from the poverty associated with the downward mobility of mental illness.
The evaluation team also noted that training is 'vital and important' as this 'validates the role and makes peer workers feel more accountable, responsible and accepted as professional members of the team.' Training and support (and supervision) is seen in other peer worker studies as important (King et al 2009; Hutchinson et al 2006; Armstrong et al 1995). Nestor and Akins (2006) caution about managing hazards from re-exposing peer workers to distressing memories or trigger situations
Orwin (2008) sees effective supervision as crucial, and notes that peer support can be undermined by inappropriate expectations. Specifically, his view is that peer support should never have to meet clinical outcomes or, for example, show a direct relationship between the use of peer support and reduced inpatient admissions. Orwin (2008) makes four recommendations in the New Zealand context:
- there is scope for different peer support philosophies and service structures;
- Peer Support Workers (PSWs) need to receive credible training consistent with their role—the sector is strongly urged to engage in debate to develop a minimum level of competency and a career pathway for PSWs;
- there are sufficient supervision structures for PSWs;
- there is a need to resolve the serious obstacles to the continued development of service user-run peer support, such as organisational capacity and insufficient management capability.
Glover and Turner (2008) note that the collective peer knowledge base is still emerging and that much more effort is required to solidify its articulation and identity. They also observe that to date, within the mental health workforce in Australia, roles that draw on lived expertise (as opposed to learned expertise) have been restricted primarily to advisory or consultancy roles. They observe that in Australia few services have seen the potential to use the capability that 'people have gained in their recovery journey'.
Effectiveness: are programs making a difference?
It is beyond the scope of this review to propose an evaluation framework for the mental health initiatives discussed in this report. There are many variables to take into account when determining whether programs are making a difference, including client factors, service mix, social supports, access to services, cost of services and determining unmet client need. A simple outputs, as distinct from outcomes, model would in itself still be complex. A framework that would measure outcomes would be considerably more difficult.
Dickinson and Glasby (2008) note that:
Outcomes differ from outputs as they are the total external consequences of services or initiatives delivered, rather than simply the products. For example, the numbers of older people in residential care or living independently in a specified period refer to outputs, but they say little about whether the life of these older people is good or bad relative to the norm.
In approaching an outcome model, it would be essential to have clearly articulated:
- goals that programs are to achieve;
- indicators of success;
- benchmark measures against which progress over time can be assessed;
- robust data collections and management systems that provide necessary data.
Data would need to capture:
- client/family/carer outcomes;
- provider outcomes (services and clinicians);
- system outcomes such as access (for example, reducing unmet need; out-of-pocket costs for clients);
- some measurement of social impact (for example, reductions in acute episodes; reductions in substance abuse; increased employment participation);
- broader public perceptions (for example, reduced stigma);
- the effectiveness of partnerships and collaborations in contributing to outcomes;
- cost and cost benefit.
The work on outcomes to date has been informative but sporadic. The following discussion demonstrates that more can be done to concentrate on measuring the results of interventions and to take up and use this information in policy and practice.
MHCA (2006:18) discusses the Prevention and Recovery Care (PARC) model which is considered good practice in Victoria. PARC provides strong support for people either leaving hospital or at risk of experiencing a crisis that may lead to hospitalisation. Among its strengths are the collaboration of clinical and community support providers and the removal of consumers from the hospital culture. In addition, because it is a community-based service it is easier to maintain links with family and carers. It also fosters strong peer support through social and recreational activities for residents. However, because it is a residential program, PARC does not seek to maintain people in their own home.
MHCA (2006, p. 25) contends that from the three PARC examples cited (Shepparton, Melbourne, Bendigo) it is clear that the model has important strengths and is very capable of providing strong community support to people in the sub-acute stage of their illness. This is because in regard to the model:
- the approach helps to keep people out of acute care and away from the hospital culture;
- people who have used the service and have provided feedback have indicated that they prefer it over hospital-based care;
- the model is community-based, which makes it easier for people using it to maintain links with carers;
- there is a Step Up component, which is designed as an early intervention strategy [PARC's service guidelines state that it '...offers an important alternative for early intervention with those consumers in the early phase of relapse'];
- the model is less expensive—as stated by the Manager for Adult Mental Health Services with the Victorian Department of Human Services, the per person per day cost under the PARC model is $339 while the daily cost per person in hospital is $590.
The Fourth National Mental Health Plan identifies indicators to be used to monitor its success. These appear in five priority areas16, each with varying mixes of identified indicators 'currently available' and 'requiring further development'. There are 13 in the former category and 12 in the latter. New arrangements are foreshadowed for public reporting by service organisations, to be accompanied by incentives and supports to participants. The key gaps identified in the plan are in 'measures of consumers' experiences of services, recovery-based outcome measures and collections that cover the growing specialised mental health non government sector.' During the first year of the fourth plan, an updated National Mental Health Information Development Priorities document is promised.
In 2003, early in the life of the Third National Mental Health Plan 2003–08, the Australian Government established the Australian Mental Health Outcomes and Classification Network (AMHOCN) 'to provide leadership to the mental health sector to support the sustainable implementation of the [national] outcomes and case-mix collection as part of routine clinical practice' 17 (Commonwealth of Australia 2003).
AMHOCN appears to concentrate its efforts on public sector clinical mental health service data collection, training and research. Its overall progress towards its vision of the introduction of outcomes and case-mix measures is unclear.
Looking at the Third National Mental Health Plan, Hickie et al (2005) criticised the lack of specificity of its 34 general or process outcomes. Rather, Hickie et al (2005) proposed five 10-year national targets for mental health outcomes. They concluded that: 'Continuing to monitor systematically and then report annually the experiences of those receiving care should be a fundamental aspect of all government-funded mental health systems.' The Third National Mental Health Plan (Commonwealth of Australia 2003) had stated that mental health research 'must answer economic as well as clinical questions' and it noted that 'research in this area is in its infancy and will be promoted through the period of the [Third Plan].
' While Whiteford and Buckingham (2005) pre-date the 2006 COAG initiatives, their observations made in the context of the life of the Third National Mental Health Plan have a timeless quality. Moving from input and process measurement to outcome measurement was seen as 'ambitious, particularly in improving data quality from hospitals'. Whiteford and Buckingham (2005) commented that '... considerable work is needed to make these measures meaningful to clinicians in routine clinical practice and to build a culture which values outcome information within the mental health sector.'
16 - Social inclusion and recovery; prevention and early intervention; service access, coordination and continuity of care; quality improvement and innovation; accountability—measuring and reporting progress. (Commonwealth of Australia 2009, pp. 44–45.)
17 - See http://amhocn.org for details of recent reports and special projects. In the latter category, AMHOCN finalised in 2008 a special project on Carer Outcomes Measures. It concluded that the introduction of an instrument to routinely measure outcomes for carers was 'neither practical nor feasible' at that time.
There is also some overseas literature that seeks to convince sectors of the clinical community of the virtues and methodology of outcomes reporting, but practical examples of outcomes results are scarce. For example, while an article by Greeno et al (2007)—'The Need to Adapt Standardized Outcomes Measures for Community Mental Health'—its main message is on survey design in community mental health settings. It argues rather obviously against long instruments (burden of time and paperwork) and structural features that increase 'cognitive complexity'.
Mullen (2004) notes that while evidence on social work intervention effectiveness has mounted over the past decade, 'little has found its way into everyday practice' and the profession needs to 'move rapidly toward evidence based practice models ... derived from outcomes research.
'Bliss (2007) outlines, again in a social work context, a nine-step model18 that smaller substance abuse treatment programs can use to implement an outcomes measurement system. The article has wider application in mental health. It notes that the early construction of a concise (in this case, one page) logic model is 'key' to the system. The article provides practical examples of output and outcomes measures.
The Boston Consulting Group (BCG) (2006) in its report on improving mental health outcomes in Victoria proposed four outcome measures for mental health:
- lower prevalence of mental illness in the population;
- increased economic participation and workforce productivity for people with mental illness;
- lower mortality and morbidity resulting from mental illness;
- increased community participation for people with a mental illness.
The report proposed six high-level progress measures for the above, as well as 11 intermediate progress measures
In the United Kingdom, Public Service Agreement (PSA) 18 (Her Majesty's Treasury 2009) notes that one in six adults was assessed as having a neurotic disorder. This agreement, which also deals with other activities of the lead department (Health), identifies five key indicators and the department's principal partners, including the Department of Communities and Local Government. Of the five indicators identified in the PSA, indicator 4 and particularly indicator 5 are most relevant to mental health:
- All Age All Cause Mortality (AAACM) Rate;
- difference in AAACM between England average and spearhead areas 19;
- smoking prevalence (among population aged under 16);
- proportion of people supported to live independently (aged over 18);
- access to psychological therapies
18 - Program analysis; specify inputs; specify output performance measures; specify quality output measures; specify outcome performance measures; assess external factors; develop a management information system; assign responsibilities; implement the outcomes measurement system.
19 - The 20 per cent of areas with the worst health and deprivation indicators.
Indicator five is more explicitly expressed as: 'Proportion of people with depression and/or anxiety disorders who are offered psychological therapies.' A baseline was to be determined by winter 2008– 09 as new datasets are involved and then reporting was to take place quarterly.20
According to the NZMHC, about one in five adult New Zealanders experience mental health or addiction problems.21 The current National Mental Health Strategy is detailed in Te Tāhuhu: ImprovingMental Health 2005–2015: The Second New Zealand Mental Health and Addiction Plan (Te Tāhuhu). Te Kōkiri: The Mental Health and Addiction Action Plan 2006–2015 (Te Kōkiri) is the associated action plan.Both are published by the NZ Ministry of Health.
Te Tāhuhu sets out the 10 leading challenges and outcomes that the New Zealand Governmentexpects the mental health and addiction sector, state and territory services and other agencies to pursue in the period up to 2015. Outcomes include all New Zealanders making informed decisions to promote their mental health and wellbeing. Outcomes also include people with experience of mental illness and/or addiction having the same opportunities as everyone else to participate in the everyday life of their family/whānau, communities and society.
In its Statement of Intent (SOI) 2009–2012, the NZMHC notes that in its previous statement the Commission focused on social inclusion and collaboration, and that its current SOI focus is on the development of recovery-focused services.22 One of the Commission's strategic objectives is supporting effective funding. It comments: 'Effective funding is possible only with clearly stated outcomes. This includes both short and long-term outcomes.
' In summary, the Commission's longer-term outcomes are of recovery and improved wellbeing for service users. It has also identified the results of more immediate impacts23 —effective funding, quality services, and reducing stigma and discrimination. It aims over the next three years, where possible, to measure both immediate impacts and longer-term outcomes for each.
The clear implication is that, while outcomes measurement in mental health is important, progress in this area is 'pending' in Australia, the United Kingdom, and New Zealand. At both national and service levels, Whiteford and Buckingham's 2005 challenge to 'build a culture which values outcome information within the mental health sector ...' remains topical.
A key issue in evaluation is identifying the contribution partnerships make in achieving improved outcomes. Glasby and Dickinson (2009) point out that despite their prominence as potential improvement mechanisms, partnerships have so far failed to demonstrate empirically that they improve user service outcomes. Extensive work has been undertaken on the process of forming and working in partnerships but little on whether they actually make a contribution to improved client outcomes. This has lead to some questioning of partnerships or at least their priority in improving services outcomes. Further work in this area would be expected to shed light on the most effective partnership approaches to meet particular circumstances and how partnering organisations can receive the most return from their investment of time and resources in partnerships.
20 - Data are to be provided to the Department of Health by Primary Care Trusts, including access to GP-based the Quality and Outcomes Framework (QOF) [a system for the performance management and payment of GPs in the National Health Service in England, Wales and Scotland. It was introduced as part of the new general medical services (GMS) contract in April 2004, replacing various other fee arrangements. Source:Wikipedia]
21 - Source: New Zealand Mental Health Commission website www.mhc.govt.nz (accessed 29 November 2009)
22 - The change in focus is because 'the new Commission believes that while social inclusion and collaboration are important objectives, a clear focus on improving outcomes for service users and their families aligns more closely with the expectations set by our legislation. Moreover it will be clearer for the sector and the public, and aligns with Government priorities for mental health care. (NZMHC SOI, p. 5).
23 - NZMHC SOI, p.23. and working in partnerships but little on whether they actually make a contribution to improved client outcomes. This has lead to some questioning of partnerships or at least their priority in improving services outcomes. Further work in this area would be expected to shed light on the most effective partnership approaches to meet particular circumstances and how partnering organisations can receive the most return from their investment of time and resources in partnerships.
Cost effectiveness
Information on cost-effectiveness in mental health is limited. At one end of the spectrum, the Canadian Senate inquiry into mental health (Parliament of Canada 2006) quoted a paper 24 produced for WHO noting that 'community-based mental health services generally cost the same as the hospital-based services they replace'.
In context, the WHO paper also observed that: 'Cost-effectiveness studies on deinstitutionalization and of community mental health care teams have demonstrated that quality of care is closely related to expenditure.' It argued for a balanced care model based on community services close to the population served, with hospital stays as brief as possible, promptly arranged and used only where necessary.
In Victoria, the BCG (2006) estimated that the economic impact of mental illness in the state amounted to around $5.4 billion annually. Its report was prepared in the knowledge that a national mental health care plan was to be considered a month later, in July 2006. The BCG estimated that a:
One per cent reduction in the burden of mental health in Victoria would cost in the vicinity of $26m and could deliver around $7 million net benefit to the economy when private economic benefit is added to the fiscal benefits accruing to both levels of government from improved workplace productivity and participations. In addition, the investment will deliver better social outcomes.
It noted that extra funding alone would not be enough, pointing to a need for more workforce capacity and capabilities, and for more collaboration (and less fragmentation and complexity) across the whole mental health system.
In 2006, a South Australian mental health recovery-based peer support service for hospital avoidance and early discharge was evaluated after its first three months of operation. Cited by Lawn et al (2008) as an example of consumer driven and operated service, 49 support packages involving 310 hours of support were provided during the pilot period, saving 300 bed-days. The savings were $93,150 after project set-up and delivery and administration costs, totalling about $19,850, were deducted. Normally, about 30 per cent of patients relapse to hospital within three months. Although the short pilot period intervened, relapse rates were only 17 per cent during the pilot.
An example of the sort of evaluation approach that can be adopted is the Stage 1 report of HASI, introduced earlier in this report. The program aims to 'assist people with mental health problems and disorders requiring accommodation and support people to participate in the community, maintain successful tenancies, improve quality of life and most importantly to assist in the recovery from mental illness'. The HASI Stage 1 evaluation, a two-year longitudinal study, showed significantly improved outcomes for the target group in areas such as:
- access to and stability of housing;
- increased community participation, for example, social networks;
- improved physical health with more regular access to general practitioners and specialists and increased levels of exercise;
- increased psychological wellness, including a decrease in psychological stress;
- increased connection with community mental health services;
- improved family connectedness.
Importantly the HASI Stage 1 evaluation linked some of these improvements to strong partnerships between health, housing and NGO sectors.
The cost-effectiveness component of the evaluation showed considerable gain for the $457,530 cost per participant through reduced hospitalisation, stabilised housing, increased social, educational and employment outcomes and decreased imprisonment.
This approach to evaluation, while resource intensive, addresses to some extent one of the key gaps in research to date: assessing the contribution of partnerships to successful program outcomes.
24 - Parliament of Canada 2006, p.92, quoting from Thornicroft G. and Tansella, G 2003, What are the arguments for community-basedmental health care?, Health Evidence Network report for WHO Regional Office Europe: Copenhagen.
(Accessed at www.euro.who.int/document/E82976.pdf on 15 December 2009).
Conclusions
The key policy implications from this review are as follows:
- Mental health problems are a major and increasing burden of disease in Australia. Despite recent national agreement to a mental health action plan and increased funding, major problems persist that will inhibit real improvement in outcomes for those with mental health problems and will impede attempts to reduce the growth of the burden.
- Mental health results in poor health and wellbeing for sufferers and has negative social and economic consequences for society as a whole. Some groups of the population, such as Indigenous people, CALD groups and people living in rural and remote areas, face particular disadvantage in accessing services.
- There is strong evidence from Australia and overseas that approaches to mental health at a population level require tackling the problem as a social as well as a health issue. Community supports, access to affordable housing and recovery approaches that support people to get on with their lives are all essential ingredients of effective mental health services.
- Nationally, through the Mental Health Action Plan, and through state and territory action plans there are commitments to these population health and recovery approaches. These approaches had also been endorsed in successive National Mental Plans since the late 1990s. Victoria has had these principles explicitly in its plans since 1999 and other jurisdictions have gradually included them as they update their plans or develop new ones.
- A comprehensive review by the Senate SCCA found that despite commitments and an injection of significant new funding, little progress had been made in key areas, including:
- coordination of services within governments and between governments and NGOs;
- engagement of consumers;
- improving equity of access to services for rural and remote dwellers and some city residents;
- failure to improve access for people with complex conditions and for special groups such as Indigenous, CALD, youth, aged and people in prison;
- access to affordable housing and support in finding employment;
- serious and continuing workforce shortages;
- lack of evaluation and outcome measurement of new programs.
- The literature supports the conclusion that effective mental health strategies require whole-of-government approaches. The welfare, housing and employment sectors are essential partners and without them health sector approaches alone will not address the problem at population level.
- There is a good body of evidence to guide policy development to create good service practice. Key factors include: much greater engagement with existing NGO community services that enable more tailored and flexible service delivery to meet the needs of individuals; significantly improved coordination across all services; capacity building for individuals to identify their needs better and to articulate these to service providers; building on existing family and social supports as part of the recovery process.
- While workforce shortages remain, more innovative approaches for using the available workforce and family, carers and 'peer workers' need to be considered. There is strong evidence that peer workers (people who themselves have suffered from mental health issues and who provide guidance and support to others who are suffering) can be an effective workforce tool. Other potential measures include providing better incentives for professionals to provide services away from city centres.
- There is good evidence to support the introduction of innovative and more flexible models of care to supplement traditional service-oriented approaches. These include: short-term home support and respites services; safe houses; telephone support; outreach services— especially for crisis support; family support, including host families where appropriate; and longer-term funding support for individuals as required.
- Creation of a learning culture for the sector that encourages sharing of information, evaluation and commitment to improvement based on evidence.
[ Top ]
B1. Snapshot of individual initiatives—
The Personal Helpers and Mentors Initiative
Objectives of PHaMs
PHaMs aims to increase opportunities for recovery for people who have a severe functional limitation as a result of a severe mental illness. This primary aim is underpinned by three secondary outcomes:
- increased access to appropriate support services at the right time;
- increased personal capacity and self-reliance;
- increased community participation.
Design of PHaMs Principles guiding the delivery of PHaMs
PHaMs focus of recovery is illustrated in the set of principles to which both participants and Personal Helpers and Mentors are expected to adhere:
- mutual respect and compassion between participants, Personal Helpers and Mentors, families and carers where relevant;
- empowerment of initiative participants;
- strong relationships and trust between participants and Personal Helpers and Mentors, which extends to families and carers where relevant;
- commitment to achieving positive outcomes for participants;
- flexibility in providing support to participants;
- collaboration between key partners, including the participants themselves, families, families and carers and other service providers, to provide holistic support to initiative participants;
- involvement of participants, families and carers (where relevant), in service planning and evaluation.
A key element of PHaMs is its emphasis on community support and social connection as an integral component of recovery.
Eligibility
The initiative is open to people aged 16 years and over, whose ability to manage their daily activities and to live independently in the community is severely affected by mental illness.
Participants do not require a formal clinical diagnosis of mental illness to enter the initiative but they are encouraged and supported to access clinical treatment (as appropriate) in the course of the initiative. Eligibility is usually restricted to the postcode allocated to the PHaMs service. However, there is capacity on a case-by-case basis to service participants from outside of postcode allocations.
Recent policy changes will allow PHaMs providers to service up to 10 per cent of participants from outside of their allocated postcodes.
Information sources for this overview
The following information is a compilation of interviews with 22 services, state and territory government representatives, peak bodies and the survey of PHaMs services. It also draws on a survey sent to 75 PHaMs providers, the response rate for which was 72 per cent.
Our understanding of client views on the initiative was derived from more than 150 interviews with individual clients, telephone discussions and focus groups during service visits. Most clients interviewed had severe and persistent conditions and many had been participants of the initiative over a period of two years. We have also analysed case studies in the service reports as well as approximately 300 cases published by the Mental Health and Autism Branch.25 Quotes from clients represent commonly expressed views and illustrate the major themes that emerged through client interviews.
Client characteristics
In services visited a high proportion of clients had severe and persistent illness and had not progressed for many years until joining PHaMs. They were referred from many services, mostly mental health clinics or other health services.
A smaller proportion of clients who were less ill or who did not have a diagnosis used the initiative. The reasons for having no diagnosis included the stigma around mental illness, which had caused some clients to delay seeking help or to delay in confirmation of a diagnosis even while they had functional limitations which prevented them from living a full and normal life. In this situation such clients were not being assisted by mental health services but in many cases were referred from Centrelink, Child Protection, employment agencies, other community services or were self referred.
In some services a high proportion of these clients had dependent children, depending on the population profile in the service catchment area. For example RUAH (service provider) estimated that 30 per cent of its 60 clients had dependent children.
Services were also asked to report on whether clients were members of special groups which constituted a high priority for government action. Most of these groups were also highlighted as priority groups in the guidelines. They include: Indigenous Australians, members of the Stolen Generation, people from CALD backgrounds, Forgotten Australians Care Leavers, people previously institutionalised, people with drug and alcohol co-morbidity, mental health and intellectual disability problems, people who are homeless or at risk of homelessness, humanitarian entrants, and clients with children of school age.
The highest representation of these groups is people with drug and alcohol co-morbidity, and people with both mental illness and an intellectual disability. These are shown in Figure 18 and Figure 19.
25 - 'Personal Helpers and Mentors (PHaMs) Shared Stories', Commonwealth of Australia, 2009.
Figure 18: People with a drug and alcohol co-morbidity in PHaMs services
Figure 19: People with mental health and an intellectual co-morbidity in PHaMs services
People who have been previously institutionalised or incarcerated are two groups with specific needs that should be considered by service providers for PHaMs. Their presence in PHaMs is shown in Figure 20.
Figure 20: People in PHaMs services who have previously been institutionalised or incarcerated
PHaMs providers are also expected to consider the particular needs of Indigenous people and of people from a CALD background. Their representation among clients in PHaMs services is shown in Figure 21. Most services have very low percentages of these groups amongst their clients, though with CALD background clients represented a little more at the level of 11 to 20 per cent of clients.
Figure 21: Indigenous people and people from a CALD background in PHaMs services
Client perspectives
The following comments illustrate the major themes emerging through client interviews.
I used to be hospitalised two to three times a year for depression and suicide attempts and I haven’t been in hospital for about 18 months now. (Client of 2 years about to exit PHaMs)
It gives me a lot of inspiration—perhaps I will be able work again one day.
David really understands what I am going through.
- The recovery approach is highly effective in engaging clients, generating their trust and empowering clients to achieve goals.
From the client’s perspective the approach is respectful and empowering. Most clients said it took about six to eight weeks to trust the service because of previous unpleasant experiences with mental health services. For the first time when dealing with mental health problems these clients believed their views were not only heard but acted on.
They found the services more respectful and not as demeaning as with medical services. This in turn motivated these clients to approach services with commitment and confidence.
Some client views:
Being listened to was a key factor for me in deciding to trust the service and in summoning the courage to try something new.
I know myself best and I like being in charge of my own progress. I find it scary and demeaning when doctors and others take over. I lose confidence in myself and just do what I am told.Clients appreciated being involved in discussions with other services contributing to their recovery.
- They liked the goal setting and planning approach to focus their effort.
The development of plans for progress gave clients focus and they appreciated the capacity to set achievable goals and then to review and expand their plans as their confidence and capacity increased. Clients also appreciated the development of plans for emergency situations because it reduced their uncertainty and anxiety about sudden relapses and the impacts on their families.
If I get sick my kids know what to do, who to contact and where to go. My mail will be collected and my electricity won’t be cut off.
My dog, my best friend, will be looked after.
- Being able to work at their own pace makes the process of recovery less intimidating.
For many people, getting out of the house, taking public transport and even shopping are very challenging activities. The tailoring of plans and the flexibility to adapt them progressively allows clients to proceed at their own pace. Clients found this less daunting at the outset and it allows them to build their confidence as they progress. They feel less pressured by what they see as artificial milestones and deadlines. Some comments were:
It took a long time to leave my house as I hadn’t been out much for at least 10 years. I used to collect my mail at night and rush down to the supermarket only when I had to and when it was quiet. At first my worker used to visit me at home. Once I ventured out with my worker I think I improved a lot more quickly. Now I go out to meet my worker at a coffee shop, use the buses and am doing some volunteer work. My worker and I are discussing a TAFE course and I am feeling quite excited about it.
My worker started me cycling to get to the gardening group. I was very reluctant but he came with me, then started meeting me half way. Now I cycle everywhere. I also feel better because of the exercise.
The program recognises that it can take some time for recovery. It is such a relief to find something that is not limited to six sessions or a 5 minute consultation. That just doesn’t work.
- Outreach services are really appreciated as many express feeling intimidated by institutional settings. The ability to meet their counsellor in a familiar setting and on their own terms was found to be a much more positive experience. Clients found that they established trust in the process more quickly. For many it also avoided difficulties accessing transport and coping with unfamiliar settings, especially at the outset of their program. The following comments illustrate the points:
It makes a big difference not to have to sit facing someone across a desk. There is always a sense they are judging you.
I feel as if my support worker and I are having a conversation between equals. She meets me where I feel comfortable and respects my views.
Getting to the service is too hard so I appreciate that the worker meets me where it is convenient and I don’t have that stress.
- Clients report being able to do a range of things they couldn’t do previously, such as establishing daily routines, taking public transport, cooking their own meals, conversing with other clients and looking after their room or house.
- Learning to recognise symptoms of problems before total relapse of a condition, to learn and apply management strategies like returning to a GP or psychiatrist, or applying what had been learned about self management was highly valued.
- Clients also reported that they now realised the value of being re-engaged with the health system and that it had an important role even if they found it confronting, uncomfortable or disagreed with treatment. They especially appreciated the support of their ‘worker’ when they wanted a medication review, or needed someone to help them express what they wanted.
The fact that my worker came with me to the psychiatrist made all the difference to my confidence.
- Clients were also connected to a range of services they were not utilising, for example, Centrelink, housing, public transport, libraries and support groups.
- Social isolation was reduced. For many participation in interest groups such as gardening, art, drama and music gave them a sense of connection with people who had similar interests, could understand their perspectives and helped reduce their sense of isolation. They were an important first step for many in developing skills, building on their own talents, and restoring skills in working with others.
- Clients expressed appreciation about the involvement of peer support workers:
- Clients have a sound understanding that while they don’t have to progress at a pace beyond their capacity, there is an expectation that they will comply with their recovery plans to the best of their ability and that they will need to exit the initiative when they are well enough. They appreciate the flexibility of approach.
Overall clients reported improved confidence, more knowledge about their condition, more connectedness with family members, with a range of services such as Centrelink, housing, employment, and social and community inclusion. They reported increased ability to manage their lives, a sense of achievement in what they had achieved and hope in the future. Overall they reported more resilience, problem solving skills, healthier lifestyles, improved quality of life, improved security, improved family and community relationships.
The carers and relatives of PHaMs clients also reported significant progress, more understanding of mental health conditions, how to pick up signs of deterioration, how to live and relate more effectively to them and understand recovery principles and processes. They reported improved health and wellbeing. The recovery approach gives them more hope for improvement and confidence in the future.
Service provider perspectives
Services believe that the recovery approach results in clients generally achieving pleasing results, often well beyond their own expectations. They appreciate that there is a sound evidence base supporting the philosophy.
Staff report that the recovery approach is also highly respected because it gives them the flexibility to offer the most effective approach to clients. For many the use of the model was a key factor in their deciding to join PHaMs.
Client outcomes
Figure 22: Outcomes for clients in PHaMs services
It is not surprising that at this stage in the life of PHaMs, the shorter-term outcomes are the most evident to services. Outcomes such as improved family relationships and reduced hospitalisations will take longer to be evident, given that many services had been fully operational for only 12 to 18 months at the time of the survey. For the longer term, the most frequent outcomes cited included: taking up opportunities for education, taking up opportunities for employment and getting access to and maintaining housing.
A key feature of the recovery approach is that clients participate fully in making decisions on their recovery plan. Clients are assisted to set their own goals for recovery using a strength's-based approach, and they then monitor this with the service's involvement. The goals are achievable so clients can take small steps. Once goals are achieved a new plan is devised for the next stage of progress.
From the perspective of counsellors the recovery approach provides a richer and more productive relationship with clients and increased professional challenge and satisfaction.
Comments from the survey of service providers gave more insights into how they support clients in the recovery process.
Using reflective practice with participants to encourage awareness of self-efficacy verses dependence and learned helplessness; identify and where possible stimulate various intrinsic motivations to maintain wellbeing.
One particular tool in the collaborative recovery model is the map which covers details of a client's responsibility with every step they take towards their recovery.
Constant challenging and motivational interviewing, CBT strategies.
Create plans with the client that identifies who will do what, and when. Creating mutual responsibilities that is reflected in clients' recovery plans. Plans are reviewed regularly with clients.
Listen, support, use tools to help them better identify and be in a position to set their own goals for recovery, allow participants to set their own pace.
Minimising client dependence on the service
Clearly recovery approaches enrich the relationship between counsellors and clients. However, this increases the risk of client dependence and even co-dependence between counsellor and client. Services reported successful strategies for avoiding this, including careful screening of clients before accessing the service; closer professional supervision of staff within the services team; varying counsellors, and discouraging patient contact with counsellors out of hours (for example, through availability of crisis contacts).
Some specific ideas were:
Supervision and constant reflection on interventions and whether or not they're fostering dependence. Varying workers. Emphasise their personal successes. Emphasising that the program is valuable.
This is constantly monitored through monthly supervision with the staff members team leader and manager which goes through each clients case plan to ensure that co-dependency has not been developed.
Clients are discouraged from contacting case managers out of hours and are given contact numbers of crisis contacts. Clients are encouraged to set goals for themselves and celebrate achievements.
The care coordination model means that clients are linked to ongoing service providers and community activities. Sometime the introduction of meaningful activities including volunteering and work diminish the need for support.
We assess our clients carefully, and if they exhibit a strong tendency to become 'overly dependent' we set boundaries around the amount of time we can commit to them, whilst still ensuring that they feel supported. We also link them in with other services in the community, so that they are not solely dependent on our program.
About PHaMs services
Service characteristics
Most services have around 50 clients. When client and staff numbers in Figure 23 and Figure 24 are compared it can be seen that services generally running a caseload of approximately 10 clients per staff member, as suggested in the PHaMs Guidelines. It should be noted that one service with a large number of staff did not report in the survey on the number of their clients.
Figure 23: Numbers of clients in PHaMs services
Figure 24: Staff numbers in PHaMs services
Services are generally highly dependent on Australian Government funding with an 84 per cent average of the service funding coming from PHaMs. This makes PHaMs vulnerable to change in policies and funding arrangements.
Service development
It has taken most services six months to one year to become fully established. This time was spent in recruiting staff, setting up premises, marketing services, developing policies and training staff to deliver the PHaMs model. Recruitment and training problems were primary and persistent barriers to efficient establishment, development of full capacity, and maintenance of services in rural and remote areas.
A number of key factors seem to have influenced the rate of acceptance of these new services:
- Whether the agency had an existing profile within the community sector and existing referral relationships with health, employment, schools, police and other services.
- The qualifications of staff employed by the service and whether the qualifications were known and respected by key sectors. Professions familiar to the health sector such as psychologists, social workers and occupational therapists were reported to instill confidence in clinical referring agencies. Mental health services, for example, wanted to be reassured that staff understood the issues, and could be trusted with high need clients who were leaving acute care in a fragile state.
The PHaMs service relies very strongly on referral and case management relationships with other providers and the building of these relationships was a high priority in the establishment phase.
As well, many services have experienced challenges in being accepted as a legitimate player for a number of reasons:
- existing service providers had established referral patterns which the PHaMs services cut across, causing client pathway alteration and confusion;
- many referring agencies did not understand recovery approaches and in many areas clinical staff in particular were apprehensive about the quality of service likely to be provided;
- services did not have a track record in the mental health field;
- services have insufficient staff;
- concern by referrers about the short-term nature of the funding for services may result in the service being too short-term for mental health clients, in that disruption to client services may have serious consequences for their health and wellbeing.
Services expressed appreciation for the understanding FaHCSIA has shown about the establishment time required to set up the service.
However, services also emphasised that networking and marketing requires significant ongoing effort at all levels and that it is insufficiently funded.
Developing collaborative service relationships
The work of services in establishing relationships to refer clients, and in many cases to participate in the recovery of clients, is paying off. Where the process is rapid it is usually attributed to previous working relationships, a progressive local mental health team, the service investment in relationship development, and the skill of staff in being able to outline recovery approaches and what would constitute effective working relationships with other providers. Figure 25 illustrates the range of services PHaMs works with. Caution must be used in interpreting this figure because many individual services are likely to have a more restricted working relationship profile. At an individual service level the levels of referrals from types of agencies was influenced by the previous work history of staff, the host agency (such as an employment agency), and the availability of services in the region.
Working relationships with other sectors
PHaMs have developed relationships with a broad range of services to meet complex needs of clients: health services, correctional services, alcohol and drug services, employment and housing to name a few. The pattern of referrals reflected the capacity of the service to set up relationships with sectors within the current context.
Figure 25: Services that PHaMs services work with
Figure 25 provides a broad overview of the wide range of sectors PHaMs works with to ensure clients needs in furthering the recovery process. At face value the Figure presents a positive picture of progress in work in relationship building is paying off but caution needs to be applied because many relationships are still superficial and the depth of collaboration and more enduring relationships and systems and structures to support collaboration are still being developed. Services report that much more work must be done to ensure that sectors have more appreciation of each others' work and how collaborative work can strengthen client progress towards recovery. Many services report that efforts to establish collaboration with state and territory governments and to encourage clinicians to refer clients to non-government community-based services have had limited success.
There are a number of reasons for this. Expectations differ between sectors based on historical patterns of services. These are sometimes exacerbated by varying organisational cultures and ways of operating, such as record keeping and referral processes. These expectations have a large influence on the depth of the service relationship and the type of collaboration activity.
Client access to services
Referrals are the most important source of clients and their pathway to service. Sources of referrals are widespread and reflect the catchment area, historical relationships with the parent agency for PHaMs, for example, an employment service or a broad based community service, and success in networking and forming service agreements with relevant agencies. Referrals constitute the first step for at least some level of collaboration to improve client health and wellbeing.
Amongst the referral sources for PHaMs services self referral and referrals by GPs and other community services, are three sources of referrals where some services are getting quite a large proportion of their referrals. Figure 26 shows the percentages of referrals from GPs and community-based services.
Figure 26: Percentages of referrals from GPs and community services to PHaMs services
Figure 27 shows that the majority of services are getting between 11 per cent and 30 per cent of their referrals from self-referral. This supports the policy decision that clients need not have a diagnosis to enter services.
Figure27: Percentages of self-referrals to PHaMs services
In site interviews most services noted they would like to have more referrals and an ongoing relationship from GPs, with the initial contact usually initiated by the PHaMs (in an effort to improve the health and wellbeing of clients by connecting them with a health service). Working with the Divisions of General Practice has provided a more fruitful avenue for many in improving knowledge of what the sector can provide. Nevertheless, as Figure 28 shows, GPs are a source in varying proportions for most PHaMs service providers.
Most services are getting fewer than 20 per cent of their referrals from drug and alcohol services (95 per cent of services), another mainstream agency (93 per cent of services) and a family member or friend (98 per cent of services).
Many services interviewed reported that developing relationships with mental health services and with the health sector generally had been difficult, although the situation is gradually improving. The causes for this difficulty are many but the main one is lack of understanding of psychosocial recovery and what PHaMs can provide.
Sometimes GPs, psychologists and psychiatrists, seem to have little knowledge of individual psychosocial rehabilitation. They are unaware of evidence that demonstrates the enormous benefits for clients and the evidence that these kinds of services can provide an average reduction of more than 50 per cent in cost of care due to reduced hospitalization. Studies have shown that clients with a diagnosis of schizophrenia may have a higher potential for recovery than previously thought (R Burton Psychosocial Rehabilitation Services in Community Support Systems Psychiatric Services April 1999 Vol 50 No 4). In some cases they may be unaware of best practices in regard to self-management and chemical treatments. In one case a GP would not provide his Care Plan to the client or PHaMs!
PHaMs services also report that the differences in beliefs about treatment approaches is another barrier to clinical and community services working effectively together. Lack of familiarity with approaches to psychosocial rehabilitation and a lack of respect for community-based services in their ability to take care of clients were common issues cited by PHaMs services.
Some clinical services do not value the work or opinion on PHaMs staff believing them, falsely, to be unqualified. We have had an incident where we were removed from a care team as we allowed the client to be self directed and in line with the recovery model and hearing voices model. Some referral process are too clinical and referral information is too intrusive for example, PDRSS is very invasive information so that people can attend a group activity. Some services have wanted to refer unsuitable applicants especially where there is a service gap for example ABI or Intellectual disability and working relationships are damaged when someone does not fit the eligibility.
The pressures on acute mental health services have sometimes led to less than optimal approaches to client care.
We have found constraints exist with working with government bodies, as it has been our experience that they appear somewhat reluctant to work with us in the NGO sector. They appear overworked and often refer clients to PHaMs in order to exit them from their books, without utilising the best approach for clients. We ensure that we find the most sustainable outcome for clients; however we have found it very difficult to work with government departments, as they often do not have the time or inclination to provide a long-term solution to clients, through developing an integrated case management approach.
Figure 28: Types of collaboration by PHaMs services
Collaborative work is time intensive and it is difficult for all service providers to find the time to generate the levels of trust and the systems to underpin good case management. With experience and developing program maturity the programs are improving.
Maintaining effective lines of communication requires particular planning attention where the staff of many services work part time and are also often out of office providing service in other centres; Particular energy has been necessary to form positive relationships between non-government and government services, due in part to the perception by govt. employed professionals that they have more responsibility and expertise in supporting clients. Non-government services have worked for a longer period of time with other non-government services and are familiar with collaboration and partnerships, especially in rural regions where services are less available. More recently Mental Health teams have been more responsive to the establishment of partnerships and more effective lines of communication.
Another commonly mentioned difficulty in collaboration for PHaMs services was that it takes time to keep the communication and interaction necessary for good collaboration working and this is difficult for all services — both government and non-government to manage.
Time management due to pressure of client work as a priority, geographical distance of services; clashes in service style with Area Health Services; competition for available services such as drug and alcohol Rehab services; Availability of Housing services.
Time availability with the intensity and outreach nature of the work we do in PHaMs—often difficult to find common times for this collaboration across services to occur.
Client wishes must also be taken into account in the self directed recovery approach and this can sometimes delay their involvement in other services.
Level of collaboration is determined by consent given by the participant. This has made collaboration difficult when a participant does not want to give this consent—where this has occurred (for example, due to severe paranoia, severe anxiety, bad history with a service etc.), we have had to take the time to build trust and rapport with the participant which has had a positive impact on getting this consent to collaborate—this however can take some time to achieve with some [clients].
In many cases services must advocate that other services operate according to recovery principles so that clients received consistent and respectful approaches.
History of other service providers organising case conferences without the client being involved (we advocate informally on behalf of the participant to have them involved and central to this process OR have a formal advocate attend on their behalf)—this has taken some time but most service providers collaborating with us now know to include the participant in these collaboration meetings.
Workforce issues
Most PHaMs providers noted that ensuring services were fully staffed with appropriately trained personnel was a constant challenge. System, labor market and geographical factors posed constant hurdles in efforts to recruit, retain, and provide for ongoing development of staff and this had direct effects on the quality, and sustainability of services
A total of 53 per cent of services said recruitment of suitable staff posed a problem for their services. Of this group, availability of suitable staff and salary levels were cited as being the significant factors.
Figure 29: Reasons for difficulties in recruiting staff for PHaMs
Figure 30: Challenges in retaining staff for PHaMs
The following comments from service providers illustrate the issues:
As the date for the end of the current funding agreement is approaching, clients and staff continue to enquire as to our future funding outlook. Clients have observed that if funding was not going to continue they would like as much notice as possible. This also becomes unsettling for staff who have stated that they would start looking for alternative employment early in the new year if there was no firm information/decision on future funding of the program.
People tend to use PHaMs worker positions as a stepping stone to gain experience. People who have qualifications (especially university degrees) tend to stay less than a year with PHaMs. This is also explained by much better paid job in the public sector competing directly with community programs like PHaMs.
Staff with degrees (recently acquired) see the support worker's position as a "stepping stone" to a position with more kudos for example, provisional psych or counsellor and therefore do not see the role as long term.
The nature of staffing of PHaMs services
Figure 31 shows that 39 per cent of PHaMs services have the greatest proportion of their staff with a degree in allied health or mental health, followed by 35 per cent or services with the greatest proportion of their staff having Certificate IV in community services or mental health. Only six per cent of services have staff with no formal qualification as the greatest proportion of their staff.
Figure 31: Most commonly held qualification in PHaMs services
Assurance of quality of services
The results for this question in the provider survey show that the quality assurance measures more commonly built into the management practices of PHaMs include team discussions, peer review and training rather than more formal methods such as peer review. However, as Figure 32 shows, 73 per cent of services using professional supervision as a means of ensuring quality reflects the demanding nature of the work and that quality is a major concern.
Other strategies include regular case reviews by the whole team and maintaining links with clinical and other services to ensure access to a comprehensive range of services and supports for clients.
Figure 32: Measures to ensure quality service in PHaMs
The following comments from services illustrate the range of additional strategies used by services to provide assurance that they are operating as they should.
Team discussions about philosophical standpoints and then use examples of cases. We spend a lot of time discussing equality, boundaries, recovery, collaboration etc. in our team. At least one discussion each day, usually informally but involving the whole team.
Internal Program Evaluations with focus on quality assurance and service delivery (we have set targets and increments for each FaHCSIA PHaMs outcome). We also undertake regular monthly file audits as an internal process. All staff are provided with regular monthly supervision—with access to EAP for professional clinical supervision when required (this is also limited due to cost involved in accessing this clinical external supervision), however we have used this in the past when required.
In addition to the above, my staff receive monthly group supervision by a clinical psychologist, have fortnightly professional development sessions with the whole team and come and see me whenever they have a client issue so that the problem can be addressed immediately instead of waiting for their fortnightly supervision session.
All team members have a monthly performance review, during which caseloads and KPIs 26 which are based on quality service indicators—speed of first contact, completion of EST and IRP etc. are discussed. Four files are audited each month to check for quality. Staff have a separate 1.5 hours a month with me (registered psychologist) for supervision, we have fortnightly group supervision and they also have monthly supervision provided by an external provider— psychologist. All PHaMs managers also have monthly supervision with a psychologist and group supervision. Staff are encouraged to make use of their annual training budgets for professional development. Managers also arrange additional training on crucial topics such as strengths based work etc. We provide regular feedback opportunities from participants through surveys or feedback lunches and we are starting a client representative group.
Work in partnership with clinical services to ensure recovery goals are met, maintain professional relationships with community mental health team key workers,foster partnerships between health care providers across a range of disciplines and services to enhance the capacity for multi-disciplinary care, ensure service is provided within the philosophy of being socially inclusive, contribute effectively to the teaching/training of undergraduate students by providing placement opportunities and engaging in quality research activities in the area of mental health services within the team.
26 - Key Performance Indicators
Use of peer support workers
The use of peer support workers is supported by the FaHCSIA guidelines for the PHaMs. It is noted as good practice by the literature because they have an important role to play in the recovery of clients. Benefits cited include providing insights and hope for clients and the teams, are supporting the building of trust with clients, and providing hope through being a role model. Eighty-seven per cent of services reported that they use peer support workers as part of their team.
For the model to be successful PHaMs services noted that it was important to have very clear guidelines on how peer support workers are deployed, sound training and preparation and effective supervision. Individual job tailoring is usually required. Some stakeholders expressed concern that peer support workers would find it difficult to establish professional boundaries with clients and provide advice when they were ill equipped to do so but services interviewed noted that this was a management and training issue and support for the role is high. Services also noted that they had to ensure vigilance about the health status of peer support workers for prevention of relapse.
The ability of services to recruit peer support workers varies widely. Many services undertake strategies to create employment pools. Volunteer work is often used as a pathway to employment as a peer support worker as well as free training in recovery processes.
Services most commonly have one or two peer support workers, as Figure 33 shows.
Figure 33: Number of peer support workers in PHaMs
Almost all peer support workers are paid, with only two services each having one peer support worker on a voluntary basis. In both these services there were also paid support workers. Some service provider comments about peer support workers were:
Excellent resource for understanding the services and clinical management provided by local GPs, psychiatrists, psychologists and area health. Excellent reference for demonstrating that recovery is possible and therefore endorsement of best practice and use of collaborative recovery model are credible.
Some difficulties found if peer support worker relapses. Impacts on team morale and time consuming for team leader.
Our peer support worker is an asset to the team. She comes with a wealth of knowledge which she shares openly with the team and with clients. We have not had any difficulties to date with our peer worker, as she is very aware of her own mental health triggers and takes precautions to keep herself well.
The benefits are numerous, including having someone who is a role model that recovery can occur, someone who has a slightly different perspective to other team members and who can provide valuable input, someone who can offer different interactions with participants based on mutual respect, learning and shared experience. The major difficulty has been in establishing the role, understanding how it is different from general support work, helping participants understand the role, and fitting the different roles and boundaries and ways of working of a peer, within a predominantly non-peer organisation.
Managing demand
All except four of the services responding to the PHaMs survey are managing demand greater than they can supply (Figure 34). Even without advertising, demand still exceeds supply for more than 50 per cent of services. The most commonly used methods of managing demand in excess of places available in PHaMs are referring potential clients to other services, not advertising the service, and dealing with the immediate crisis but deferring further assistance. Some services noted that relaxing the guidelines so more, but less intensive, assistance can be given to clients on enquiry might be an alternative to referring on or not being able to provide any service.
Figure 34: Methods of managing demand—PHaMs
Meeting the needs of priority target groups
The following discussion will focus on the needs of Indigenous Australians and those from CALD backgrounds.
Indigenous Australians
Most services interviewed reported great difficulty being able to attract sufficient numbers of Indigenous clients compared with the level of need and do not feel competent in serving them well. Some services stated that they did not attempt to serve this group because they had limited understanding of how to deliver an appropriate service. Notably, few of the responses reflected the strategies and techniques covered in Attachment C of the PHaMs Guidelines on the needs of specific groups.
Most services have made serious attempts to attract and serve this client group and common approaches include:
- building networks with Indigenous organisations and communities, such as Land Councils, Aboriginal Medical Services and Indigenous training organisations;
- using opportunities such as NAIDOC week celebrations, dinner, sports days, awards, service stall with the local community and other service providers;
- employing Indigenous staff and providing Indigenous trainee positions;
- undertaking cultural awareness training for other staff in the service.
The main difficulties experienced have been in getting engagement and trust from the clients and their families/communities and thus in getting referrals.
Time taken for the Service to be known and trusted by aboriginal communities, families and elders through successful and sensitive work with individuals, time taken to recruit aboriginal staff, complex co-morbidity issues.
The small aboriginal community in the site has several aboriginal health workers who attend to education, and a variety of health needs. The community does not wish to be referred to any other services or to self refer even though statistics show that there are a number of people who have mental health and drug and alcohol concerns. There has been resistance even to some health workers being appointed due to the fact that they are not from a 'family' acceptable to the community.
Understanding their specific cultural beliefs/needs and family structure. Working with the families on a holistic level to ensure appropriate services are provided that sit comfortably with the client and their family.
The demand is so high in our area that we were already full by the time we were invited to join the meetings with the elders (within 3 months of starting) we have been full ever since. I believe this has been a deterrent for them in referring people. Distance from the main Indigenous population and difficulty in reaching that population. Stigma within the Indigenous community with people being unwilling to identify as having a mental illness. Preference for mental health issues to be dealt with within the Indigenous community. Lack of availability of training for staff in how to work with people from Indigenous backgrounds.
Our Aboriginal participants have tended to engage during crises, but at other times not participated consistently unless the support has been very driven by the PHaMs worker. In some case these clients have not wanted Aboriginal workers. Sometimes we may not be sufficiently aware of the cultural diversity with this group of clients.
We have received referrals but usually the person does not want to follow through, rather, wanting to access Indigenous services.
However, many services are still achieving success in delivering services to Indigenous people. Strategies they have employed include employing Indigenous staff; building closer relationships with Indigenous community organisations (for example, drug and alcohol); and ensuring that staff undertake appropriate training, including cultural awareness.
Comments from services that are making progress follow:
Actively sought to employ aboriginal staff as essential element to the service, built the reputation of the service and slowly gained the trust and respect of local aboriginal organisations, groups and elders. Close liaison with aboriginal support services, individualised and highly flexible approach to supporting aboriginal participants, improving staff skills in identifying and meeting the needs of aboriginal participants through cultural competency training.
The service has been collaborating with the mental health teams including a Mental Health Aboriginal Liaison Officer for the Drug and Alcohol Centre which is just outside the site, and the site has been successful in encouraging and receiving referrals from three participants who identify as aboriginal.
We have completed joint training with Indigenous and non-Indigenous trainers we have liaised and networked with our local Aboriginal Co-operative and have links with the Indigenous clinical liaison officer for Southern Community Health. We have provided a meeting space for an Indigenous psychologist to meet referred clients to our service, the psychologist is not based at our service but utilises the room as required.
PHaMs staff completed training in cultural competencies, Multicultural Mental Health and Non-aboriginal staff completed Indigenous Awareness training which offers an insight into best practice methods for engaging and supporting Indigenous Australians. PHaMs works in collaboration with such services to link Indigenous participants with extended family and Elders to reconnect participants with key cultural and emotional supports. Refresh and further develop knowledge in working with multicultural communities through ongoing training, sharing of strategies and resources, through interagency participant co-case management meetings.
Challenges in meeting needs of Indigenous people
It is clear that assertive strategies must be used to engage Indigenous people. Services who were successful had established a history of providing services to this group, had well established engagement and service strategies which utilised other funding sources to serve the needs of the family and community as part of supporting the individual.
People with a CALD background
Services experienced even more difficulty in attracting clients from a CALD background. Strategies used to do so were similar to those used for Indigenous clients:
- promoting CALD communities through other organisations providing services to CALD groups and through community-based cultural organisations;
- transcultural training for service staff;
- networking and collaborative relationships with CALD organisations and organisations from which referrals might come;
- using interpreters and translators.
Challenges in working with CALD background people
Many services interviewed highlighted similar difficulties as those experienced in seeking to attract Indigenous clients including:
- lack of familiarity with the culture;
- different cultural norms associated with the care of family members;
- deep seated stigma about mental illness which influence sufferers and their families not disclose they have a problem;
- the need to have translators or workers with appropriate language competency.
Similar to MHCB and MHR services, PHaMs services found that language barriers and lack of interpreter services posed the highest constraints on service ability to offer a comprehensive and quality service. Difficulty in accessing interpreter services occurred both because of availability and cost. The lack of consistency in having the same interpreter assigned to work with the same client over a period of time posed a barrier to good service.
Concepts of mental illness and stigma associated with mental illness in many communities form strong barriers which require skilled staff and strategies tailored to each community. Services which have been funded to provide specific support to CALD communities have developed approaches highly suited to the communities served.
We have utilised one of our (parent organisation) services called Ethnic Link which has workers who speak about 40 languages. These workers are trained as language workers rather than translators and they work in a very culturally sensitive way. By utilising these workers we have been able to modify our assessment approach and ensure the participants find appropriate support services.
Isolation from mainstream community services, families hidden and different cultural understanding of Mental Illness. Language barriers make forming the trusted relationship more difficult.
Language/communication can be a barrier, (mainly at initial meetings until we are able to establish if translator/community member is needed for interpretation). Different social norms, from different cultures, and ensuring staff take the time to acknowledge and work through any specific cultural needs of the client.
Again, as with people from Indigenous background—lack of referrals coming in. We are addressing this and will be meeting with the Migrant Resource Centre again soon to organise some additional training and strengthen relationships to increase referrals coming in for this target group.
We do not receive a high number of referrals from people from CALD backgrounds. There is a lot of stigma in CALD communities around mental health, and so accessing services is often limited.
The main challenge in meeting the needs of people from CALD backgrounds has been engaging CALD consumers as their ability to participate may be limited by such things as language proficiency, migration experience, social isolation, other personal priorities such as housing and employment and lack of familiarity with how to access the mental health system. These factors are being addressed by developing partnerships with local Migrant Resource Centre and CALD Community Support Services to improve the particular participation strategy to CALD consumers.
In rural areas the scarcity of appropriate services or resource centres that providers could work with or draw on made provision of service to people from CALD backgrounds difficult.
Providing culturally sensitive referrals due to the lack of services within our service area.
Social isolation in the rural and remote setting.
Issues arising for PHaMs
The following are examples of issues which cause unnecessary barriers for service delivery and might be addressed for the future evolution of the initiative.
Eligibility issues
Residence in allocated postcode
PHaMs services are allocated postcodes which form the basis of service extent and the geographical eligibility. While this approach might serve to ensure that services are in areas of highest need it has not always achieved this and in many cases has led to outcomes such as:
- the postcodes sometimes cover business districts or other areas which have few potential clients;
- clients within easy reach of the service provider, but in a different postcode zone, may be ineligible;
- the geographical coverage posed by postcodes is often illogical in terms of actual client flows because of factors such as distances to be travelled, flow of public transport and areas of high need;
- in subsequent rounds some PHaMs clients have to travel through other PHaMs catchment areas to access their own service;
- the designation of areas poses problems for referrers who find it confusing;
- it makes it much more confusing for referring agencies who are likely to pick the service most convenient for the client and who find the NGO network of services confusing.
Services would like to be able to make their own judgments regarding intake for each client (within service criteria) as there are many factors which need to be taken into account, including urgency and level of need, the 'fit' between client needs and the availability of appropriate staff members (such as having the right gender available) and the existence of alternative services which the client may access. There is provision for enrolling eligible clients by seeking approval from FaHCSIA but this is considered time consuming, onerous and unnecessary. Overall services believe it would be better to have principles which guide intake and allow services to exercise judgment about whether a client would be eligibility for their service or needs to be referred to another service. State and territory respondents noted that postcode arrangements unnecessarily complicated the system as many related state and territory programs worked on different criteria.
Other aspects of eligibility assessment also pose problems, as described below.
Confidentiality
Services consider that requiring clients to sign confidentiality agreements to allow personal information to be shared with other services involved in their care as part of eligibility assessment is premature and poses problems. Many clients and service providers reported that clients would be anxious with this because of unhappy previous experiences and that it took six to eight weeks before they could trust the service.
Addressing alcohol and drug issues
Services report difficulty with clients having to sign commitments to address alcohol and other drug problems at entry point to meet eligibility requirements. This is particularly difficulty when clients had failed in previous attempts to get off of alcohol or drugs and did not know whether they could trust themselves. A related issue is that detoxification and addiction management services have financial implications. For clients on a pension this is a major problem. Clients who wish to undertake methadone treatment reportedly incur costs of $70 per week in some states and territories and this for many is unaffordable. This means that some have to undertake detoxification programs or use methadone as a temporary measure to help them on the path to detoxification. While services understand the need to tackle alcohol and drug issues they believe the timing is not optimal. It may take some weeks before the client can commit and many have made this step when they realise PHaMs will work with alcohol and drug services and support them through the process. Other clients simply do not disclose they have problems if it means they will be denied access to a service.
In answer to the question 'What changes would you like to the design and management of the initiative?' one respondent summed up a common issue raised in both the consultations and the survey.
Change to the eligibility criteria of 'willing to address drug and alcohol use'. It is not always realistic or possible to get a guaranteed, definitive answer to this question at the early stages of engagement. It restricts eligibility on this question may mean that many who need the service are being deemed ineligible. It is useful to gather this information, but not useful to declare someone is not eligible when they may be in pre-contemplation stage. A yes answer isn't always true either.
The Eligibility Screening Tool for eligibility assessment
A number of comments both in interviews and the survey indicated that the Eligibility Screening Tool (EST) might need some adjustment to better serve the interests of clients and PHaMs providers. Of those using an assessment tool in addition to the EST, just over 70 per cent are using an assessment tool that is recognised, and which is used in their parent organisation. Less than half of PHaMs are using the EST to evaluate effectiveness.
I believe the EST still needs some adjustment in relation to the function rating. It still pertains to more physical/intellectual illness or disorder.
One thing noted is that the EST currently includes functionally indicators only and doesn't include quality of life indicators—this is something Anglicare are exploring the use of other tools for.
EST's could become a more practical form incorporating FaHCSIA eligibility with service requirements and assessments. EST's could be filled out online by a self referring client and then automatically referred via email to the local provider.
Electronic EST, could be improved to make it more user friendly. Provision in the guidelines to provide a minimum three-month service to those clients who just fall outside the EST functional limitation score.
Funding issues
Collaborative arrangements underpin PHaMs services but there is no specific funding to build service relationships. These require a great deal of time and effort and staff are limited in what they can do given their current client load.
Another commonly raised concern is that funding for transport is insufficient to meet needs. Every service visited commented that this is a pressing issue, especially for those with large geographical areas to service.
Design and management of the PHaMs service
There were a significant number of very complementary comments about PHaMs and its management. Examples include:
I think it is the best program ever developed because of its openness to ideas and flexibility.
I can't suggest changes that would improve the design and management. I think that the online reporting, data collection assessment tool, helpdesk support, communication from FaHCSIA managers, milestones, have been efficiently managed and all procedures are not difficult for service providers to carry out.
All is good and I believe that the emphasis on client and not administration is important to the culture and delivery of the program.
None. I think this is a beautiful program!!!
Overall, we have been very happy with the design and management of this FaHCSIA program and with the level of assistance and support from our contract manager. The overall management has allowed us to focus on the clients without an over-emphasis on paperwork whilst still maintaining thorough records/files. This has enabled us to give a much higher quality of service to our clients which is extremely rewarding.
Overall assessment of PHaMs effectiveness
All stakeholders believe PHaMs is an effective initiative. Clients and service providers express high levels of satisfaction, services are filling service gaps, and the recovery model is highly appropriate to the needs of clients and successful.
State and territory government and peak body representatives also affirmed that PHaMs is effective and is making a substantial difference to the level and productivity of the service system.
However there are concerns about the number of service providers fragmenting the mental health system, the small size of many of service organisations, and the short-term nature of the contracts having a deleterious effect on clients. One state and territory health representative stated it was unethical to set up mental health services if there was no intention to fund them for the long term.
State and territory government representatives also had concerns about the lack of consultation in the early stages of the initiative when important decisions were made in the location of the services and how they might work effectively with state and territory services. However, they believed that while consultation processes with FaHCSIA were improving they could be enhanced. At the state and territory government level there is also a need for better information flows through departments as it was also clear that senior officers in the states and territories were not part of the information chain. Nonetheless most parties consulted believe that consultation was improving and look forward to building relationships with the state and territory officers of FaHCSIA so operational and pathway difficulties can be more effectively addressed daily. They believed that more formal consultation structures with FaHCSIA would improve the development of community-based psychosocial approaches.
No state or territory government had formal consultation processes with Australian Government community service agencies. Collaborative processes occur at local level between providers.
Peak bodies were pleased about the impetus given to psychosocial services but would like more serious consultation about the evolution of PHaMs and their involvement in it.
[ Top ]
B2. Snapshot of individual initiatives— Mental Health Community Based Services
Objectives
The outcomes with the MHCB sit within the broad outcomes of the COAG National Action Plan onMental Health 2006–2011.
MHCB is targeted at supporting families, carers, children and young people affected by mental illness. It is also focused on prevention and early intervention and has a particular focus on Indigenous families and those from CALD backgrounds. MHCB's broad objectives:
- develop a sound evidence base and practical framework for broader mental health intervention in a community context;
- empower and strengthen families through information, education and skills development;
- develop more effective parenting, relationships, and communications strategies employed within families that are affected by mental illness;
- provide enhanced support for children of parents with a mental illness;
- improve the emotional health and wellbeing of family members;
- increase community awareness and understanding of mental health issues and the impact of mental illness on families;
- improve family functioning and social support for families, carers, children and young people affected by mental illness;
- improve the capacity for prevention and early intervention for mental illness;
- increase resilience and coping skills for initiative participants;
- increase awareness and understanding of mental health issues in the community.
Design of the initiative
Projects selected for MHCB are evidenced-based and evidence generating and/or expand on previous research or learning. Parent organisations include existing community-based organisations already serving families or particular population groups such as Indigenous or CALD.
A particular funding requirement is that service providers should demonstrate how they were using evidence based approaches and/or further developing evidence in mental health promotion, prevention and early intervention. Another requirement is for a contribution for sector capacity building by sharing that evidence across the community sector.
Information sources for this overview
The following information combines the results of interviews with 17 services, Australian Government and state and territory government representatives, peak bodies and the survey of MHCB services.
The survey was sent to 44 MHCB service providers and the response rate was 54 per cent.
Mental Health Community Based Services in operation
Services provided by Mental Health Community Based Services
MHCB guidelines provide considerable flexibility about the types of activities or services that service providers can use to meet the needs they have identified for targeting with MHCB funds.
Services report using a range of activities to support objectives. Providers select interventions based on identified needs in their community and to fill gaps in services for education, prevention and early intervention programs.
Providers are enhancing other services though education programs for the general public to:
- Build capacity to understand and address risks to mental health individually and to know when to seek help through education programs for community members, and service providers operating in the health and welfare fields.
- Provide targeted individual and family support services, delivered through a range of strategies:
- assessing whole-of-family need and holistic care planning;
- providing services to meet individual need such as development of relationship skills, conflict resolution skills, household management skills;
- ensuring pathways of care are established and that they work effectively through collaborative work with other providers, including case coordination and advocacy;
- joint action includes work with schools, child protection, police, the Australian Taxation Office, employers, government agencies such as Centrelink, mental health clinicians, home visits and provision of information and advice about coping skills and parenting skills, peer support groups and networks for carers, with a few services specifically targeting young carers and siblings of people with a mental illness.
- Some community services are also trying to build community capacity to prevent mental illness.
Service delivery is through a combination of outreach and centre-based services. Family services are often most effectively delivered in the home environment. Care plans are developed with family involvement with the philosophy of working with their strengths and empowering them to take action in areas of need. Their progress is monitored. The approach reflects the principles and philosophy of recovery even though these principles have not been designated for the initiative.
Some key principles respondents believe underlie MHCB services include:
- mutual respect and compassion between participants and family workers;
- empowerment of participants;
- strong relationships and trust between participants and staff;
- commitment to achieving positive outcomes for participants;
- responsiveness in providing needed support to participants;
- holistic approaches;
- involvement of participants, families and carers, in service planning and evaluation.
These principles translate into:
- flexibility to configure the service to the particular needs of the client and/or their family (including outreach services);
- an inclusive approach, including no requirement for formal diagnosis and no need for a referral;
- provision of a better focused and tailored service by collaborating with other services to get the range of support clients needed—in some cases this collaboration was outside the service organisation and in other cases it was through related services in the service parent organisation.
The following summary of survey comments illustrate how MHCB principles translate into practice.
- Ability to go to client (client visits)—reduces client stress and supports recognition of rural isolation.
- Flexibility—no diagnosis required to be eligible for program. Shifts focus from medical model to being responsive to need.
- Holistic approach to service provision—allows any issue to be addressed which impacts on the caring role.
- Program Model—3 stage model moves client family through stabilisation phase, building resilience and finally social inclusion. Outcome focused approach.
- Brokerage component—provides ability to address genuine client need, service gaps, financial constraints.
- Combination of casework and community development approach—allows gaps to be addressed when identified and builds ongoing capacity in the community.
Service types and range
The following short summaries describe the services that submitted input into this evaluation. They represent a snapshot of the range of services provided to children and families through MHCB.
Mental Illness Fellowship of Western Australia
Whole-of-family assessment of need; in-home assistance with mental health management, parenting, housekeeping, relationship issues, managing conflict; linking to community activities and services especially for children; advocacy for housing, welfare assistance, job's agencies, child protection, schools, mental health clinics and hospitals.
Mind Australia
Behavioural Family Therapy program, provided to families where someone has a serious mental illness. The service is provided in their home.
NW Family Mental Health Services
We currently provide an outreach service to rural and remote communities in the NW which includes: Capacity building around families, support to children of parents with a mental illness, family or one-to-one counselling, and linkages to other support services as required.
Bundaberg Skills Centre Inc (trading as IMPACT Make Your Mark)
Community education, Support for people that live in a household where there is mental illness including, parents, carers, young people and children. This can include personalised mentored support, Client support plans, Community Links referral service, Time out for families, Chillin (social activities for teenagers, early intervention and education programs for children and adolescents aged 5–18 years being Kidz Club and KOPING based on COPMI module and Community Awareness Workshops.
Centacare New England North West
Mental Health Education for the general community (this includes carers, family and friends of persons with a mental illness and those living with a mental illness) and staff of Organisations/Services who work with Mental Health Clients, Carers and Families. The education provided ranges from 2 hour workshops on specific disorders and pathways to care through to 2 day certificate courses (Adult, Youth and Indigenous Mental Health First Aid). Some of these workshops and courses we run in partnership with HNEH Mental Health Promotion and Prevention team, HNEH CAMS Team and the Division of General Practice.
Self-help workshops—Mental Health Welfare Organisational Service staff tailored workshops for example, work life balance for DOCS, Mental Health First Aid for Joblink Plus—Workshops for persons living with a mental illness, including problem solving, coping skills, resilience, relapse prevention. These workshops are run in partnership with Billabong Clubhouse (local client service that provides day program based services for clients with a mental illness from Health, PRA, Richmond Fellowship and general community).
Six week Psycho Education groups—Adult Cognitive Behaviour Therapy course for persons living with a diagnosed mild to moderate depression (run in partnership with HNEH Community Mental Health Team) this course is linked in with the local G.P's.
Our SMILES (COPMI program) program for children aged 8 to12 years who are living with a family member who has a mental illness (linked in with HNEH Community Mental Health Team and Schools). We will be starting the 'ACE' program 2010. This is a six week program for adolescents 14 to 16 years who are showing prodromal signs of depression or are at risk of developing depression (this will be directly linked in with a partnership with schools). Dual Diagnosis workshops—in partnership with Probation and Parole. We will also expand these workshops to youth related services in 2010. Host some of the regional Mental Health Network meetings. Member of the regional HNEH Mental Health Promotion and Prevention Committee. Collaborate with Expos etc.
Multicultural Centre for Mental Health & Well-Being Inc.—'Harmony Place'
The Wellbeing Team provides Mental Health Community Education to CALD communities in the greater Brisbane area. The communities targeted are African, Pacific Islands, South East Asia and older established communities for example, Indian community.
Southern Youth and Family Services Association Inc.
Family and individual support and counselling, case management, brokerage, mediation and family relationship work, early intervention, telephone support, assessment, referral, advocacy, living and social skills education, parenting skills education, practical assistance, provision of information, conflict resolution, encouragement and general support, group work. Other services provided on behalf of clients collectively and for the community include: community development, linkages with other community groups, structural advocacy, lobbying, policy development, support to other agencies, input into inquiries, community awareness raising, supervision of placements, training.
Carers SA
Support Groups and Networks for Carers (including young Carers). One on one emotional support for Carers; Young Carers Awareness Program in schools and other education facilities Carer Mentor Program; Resource and Advice Service for Carers Community Awareness Program—including education and training workshops for Carers and service providers.
Client characteristics
Clients for MHCB are acquired in various ways, including through assertive outreach, strategies to reach the homeless, working with schools and parents, marketing services to other agencies who can refer clients (for example, health services such as CAMHS and GPs), the legal system (for example, diversion programs, child protection services), schools, and other community services such as the FaHCSIA Family Support Program. Many clients are self referred or referred by family members. Some features of the client characteristics in MHCB services are:
- The family orientation is being utilised by services:
- Half of the services have five per cent or fewer clients who are families affected by mental illness, grandparents where family members have a mental illness, families who are homeless or at risk of homelessness and non-familial carers.
- A large proportion of services have some Indigenous clients. However, it is not known from this survey whether the services are adequately meeting the needs of this group.
- Three services have 70 per cent or more of clients who are Indigenous and just over 60 per cent have no more than 20 per cent of clients who are Indigenous.
- The service reach for CALD clients seems limited compared to the need in the community.
- Seventy per cent of services have 10 per cent or fewer clients from a CALD background.
Two MHCB projects are predominantly serving Indigenous families and one is primarily servicing CALD background families. The focus of the initiative on Indigenous and CALD groups may reflect that a much smaller proportion of services have no clients who are from these backgrounds, compared with other client characteristic groups. The client numbers for these two groups are in Figure 35, which shows that Indigenous families are marginally more represented in MHCB's client base than are people from a CALD background.
Figure 35: Indigenous and CALD background clients in Mental Health Community Based services
Client perspectives on the Mental Health Community Based Service
Client perspectives were gained by speaking with more than 70 clients in focus groups and in telephone interviews, as well as information gleaned through case studies and examples given by service providers. Much of the information was able to be triangulated with views of other family members and schools.
The main themes emerging through responses are:
Prevention—increased understanding of mental health and mental illness and its triggers, preventative strategies and the importance of seeking help in a timely way.
Early intervention—especially working with children with mental illness, through strategies such as:
- increasing family resilience and developing skills in coping with the impact of a person with a mental illness on the family.
- connecting people to needed services (such as Centrelink) and helping them resolve outstanding matters such as taxation, debt reduction.
- reducing social isolation by linking clients to peer support networks.
The following examples of benefits expressed by clients illustrate the range and complexity of cases and outcomes:
- Children at risk of suspension because of truancy or bullying have been counselled and supported in developing strategies to cope. Comments from the provider, school principal and school counsellors perspective were:
Shine developed a group program on bullying which is essentially seen as a leadership program by the participants. They are learning new skills and the problems at school seem to have dissipated. They are also happier at school.
School principal: Shine's assistance in supporting the school in preventing an escalation of problems was invaluable. As well the children in the group sessions are responding well and are reporting new understanding and skills.
School counsellor: I have developed my skills by working as a joint facilitator with the Shine team and it was wonderful to have this community support for our school. It is wonderful to know they are there as I cannot meet all the needs presenting in the school. As outsiders the children gave them a high level of respect.
Grandparent: Through the support of the service I have learned how to respond to my grandson's anxiety about his mother and his grief from losing his great grandmother. His therapy with the service has helped him deal productively with his grief, he is coping better with school and he has more understanding of his mother's severe mental illness and strategies to cope with this.
Mother: I have had my children returned to me and we are now coping better. My daughters are getting over the trauma of being taken into care and the worker sees us all individually and together. We have negotiated better ways to relate to each other. The girls know they can text or phone the worker at any time. This service has been like a guardian angel.
Interviews with clients, stakeholders and evaluation reports demonstrate that at a minimum the following outcomes are being achieved.
- Families have learned strategies to deal with difficulties posed by child anxiety and the inability to deal with having a parent with a mental illness. The following comments from the family perspective illustrate the positive outcomes of MHCB:
- Increase in mental health literacy by family members, schools and community members. This enables detection of possible problems and help seeking at an early stage so illness can be prevented. Many services have education programs in a variety of settings in the community such as schools, workplaces and services which alert people to emerging problems.
- Specific outcomes reported by clients and stakeholders include:
- improving the ability of parents and schools to identify children with problems either when children are too quiet or deal with obvious problems such as anxiety, aggression and bullying, assisting with post natal depression, alerting people to the need to seek medical help; and
- supporting children to deal with grief and loss, anxiety, relationship and caring issues where their parents had a mental illness.
- Individual children and families in need have developed more effective strategies to deal with conflict and developed the skills to engender cooperation by family members, improve coping skills in dealing with everyday problems resulting in a more orderly life, and improved access to services.
- Early intervention—small group and individual case management especially in improving problematic behaviour before they escalate into major risk factors.
- working with families to reduce likelihood of children being taken into child protection; and
- working with families to improve relationships and parenting skills to reduce the risk of a child being taken into care.
- Clients also reported that they were helped to access services they didn't even know existed and they received support with housing, social welfare and other needs:
The worker comes to our home and works with the whole family, as well as my daughter.
My daughter tells me that when she starts feeling angry, instead of allowing it to get worse she can now recognise that she is thinking 'red thoughts' and decides to change them into "green" thoughts. She is now getting on better with the family and at school because we can all talk about the things which upset her.
I didn't realise that I was actually escalating my son's problems. Now I have strategies for recognising the triggers and dealing better with my anger and anxiety so I don't take it out on him.
Teenager: I know I can ring at any time, I was living on the street when I heard that this service helped young people. They found me somewhere to stay, even though it isn't a permanent home, I know they are trying to find me a place and they are helping me get into a TAFE course and they are also giving me more skills to find a job.
My former husband (who lives in another city) has a mental illness and my children feared being alone if they were there on holidays and he had a relapse. The worker developed an emergency plan with them including emergency contacts so they knew what to do, so they felt confident to go and see him and his girlfriend. They have had to use the plan and it worked, so they feel in control of the situation now.
Teenager: the worker has taken me to a couple of groups (sporting and social) and I have met new people, which is good. Also they don't know about me so I don't feel ashamed that I have been in trouble.
I recognised that I had symptoms of depression because of the seminar. I went to see the doctor and I am also getting counselling from the service. I didn't want to use counselling through Medicare because I can't afford the copayment and I knew that I might need other family members to do some counselling with me' so I went back to the service and had counselling there. My family became involved as well.
Teenager on outreach: I would never be able to have the fares to see a worker as often as I need to, I feel as if my views and needs are respected when the worker asks me where I would like to meet, and encourages me to phone him when I can't cope.
My worker comes to the school so I can just stay on after school rather than having to find my own way to an appointment. I can now understand why I am so angry and am learning to cope with school better now.
- Development of skills—coping, reframing thinking, Therapeutic interventions with individuals helps provide effective coping skills:
- Family relationship skills:
- Reducing risk factors—working with young people to address risk factors arising from homelessness or risk of homelessness:
- Making plans—for change and improvement, contingency to manage risk. Clients appreciated having goals and plans which gave them a sense of control over their lives. They also felt empowered and involved in solving situations:
- Developing greater confidence and skill in social interactions and relationships reduces social isolation:
- Community education:
Service provider perspectives on client outcomes
The outcomes for clients which services believe they have achieved are represented in Figure 36. Evidence for these outcomes is found in client progress according to their plans, feedback from group activities and evidence provided through evaluation and research. A number of evaluations of services were provided to the evaluation team.
Figure 36: Outcomes for clients—Mental Health Community Based Services
There were no common themes among service provider survey responses but the more frequently mentioned outcomes included increased:
- understanding of mental health and mental illness, its triggers, care, prevention and early intervention;
- family resilience and skills in coping with the impact of a person with a mental illness on the family.
Building service capacity in the community
An outcome for the service system that MHCB providers saw was that they actively engaged with other providers in developing service capacity across their region.
Activities providers were involved in included sharing:
- good practice information and ideas and service models;
- training for staff and information about mental health with other services and with the community sector more broadly.
Most services said they listed collaborative activities and networking as a contribution to sector development because they believed it enhanced the services available in their local area and increased access for clients and families, making the sector's impact greater overall.
About Mental Health Community Based Services
Client numbers
MHCB service models vary so Figure 37 provides indicative information about the reach of the service and the type of activity engaged in. Those with a more prominent role in community education are likely to have the largest client numbers and others with a counselling role would be limited by case load capacity. Many have a combination. Thirty-six per cent of the service providers that responded to this question had fewer than 50 clients and another 36 per cent had between 50 and 100. The remainder had more than 200 clients.
Figure 37: Number of clients in Mental Health Community Based Services
Number of staff
Sixty-four per cent of MHCB services surveyed had five or fewer staff, with two staff being the most common number (Figure 38). The numbers of full-time equivalent Full Time Equivalent (FTE) were slightly fewer than the staff member numbers, indicating some part-time employment. Many MHCB services are part of larger organisations, often sharing the same premises, so they benefit from their infrastructure (for example, Information Technology systems, training capacity and referrals).
Figure 38: Numbers of staff in Mental Health Community Based Services
Percentage of current service funding received under Mental Health Community Based Services
MHCB services are highly reliant on Australian Government funding. Fifty-eight per cent of services received 100 per cent of their funding from the MHCB and a further four per cent received 90 per cent of their funding from MHCB. The remainder received under 20 per cent of their funding from MHCB.
Developing collaborative service relationships
MHCB services collaborate with a wide range of other services (Figure 39). The large number of stakeholders reflects the needs of the wide spectrum of clients needing services as well as the sources of referrals. It demonstrates the need for extensive effort in building relationships, developing service agreements and modus operandi for collaboration with services that have a wide range of client groups, each requiring different strategies. MHCB services must develop clear ideas on the purpose of collaboration and high skill levels in networking and flexibility to adapt to varying service delivery requirements.
Figure 39: Services that Mental Health Community Based Services work with
Access to services
The two strongest sources of referrals for MHCB services are community services and self referral. Thirty per cent of MHCB services get more than 30 per cent of their referrals from these two sources.
While most services get referrals from mainstream agencies and institutions, indicating perhaps, that they are well networked in their communities, these account for fewer than 20 per cent of referrals. Similarly while most services get some referrals from child protection agencies, these account for five per cent or fewer of referrals. Not surprisingly, given the focus of MHCB services on community education and awareness raising and on families and young carers of people with a mental illness, rather than individuals who have a mental illness, many services do not get referrals from drug and alcohol or housing services. This long-standing issue is only now beginning to be resolved through MHCB services building connections with national co-morbidity initiatives.
The referral pattern varies markedly across the MHCB and depends on a number of factors—the existing service reputation and established profile across the community, the types of service offered, the effectiveness of collaboration with other stakeholders and the effectiveness of marketing. In relation to the last point many services noted that they do not market because they could not meet the additional demand this would generate.
While the majority of services are getting referrals from GPs, these account for fewer than 30 per cent of total referrals (Figure 40). Many services mentioned they would like more referrals from GPs as this is usually the first point of contact for people in difficulty. If that were the case then clients would be more likely to gain assistance in a timely way. This is likely to be a system issue as medical practitioners are familiar with referral practices to medical services but they are not familiar with the role of community services in primary health care. Percentages of referrals from GPs are shown in the figure below.
Figure 40: Referrals from GPs to Mental Health Community Based Services
Services would also like more referrals from Child and Adolescent Area Mental Health Services (CAMHS) as this type of client also need family based work or support in their schooling.
Developing collaborative service relationships
Figure 41: Types of collaboration by Mental Health Community Based Services
Benefits of collaboration commonly mentioned by the MHCB services were:
- better pathways and referrals are provided through improved networking and collaboration between services;
- improved understanding and awareness for families and clients about mental illness, and the assistance they can obtain;
- much better coordination of care leading to better service and less confusion for clients and families about the whole system and their interaction with it;
- closely related to the above, a more holistic approach to service delivery with collaboration with other services being one of the major contributing factors to being able to deliver a more holistic service.
Some illustrations of the benefits of collaborations from MHCB service providers were:
Coordinated service delivery has ensured that clients and service providers are clear about roles and direction for support—reduces overlap and confusion for client.
Innovative service responses have been developed for difficult client scenarios which would otherwise [have] resulted in needs being unmet.
Clients have utilised services that they would not have approached previously due to lack of knowledge, fear stigma and trust.
Greater opportunity to advocate for carers to mental health teams in care coordination meetings for referral of family member to community-based mental health support in addition to clinical.
More holistic support: Client has been able to supplement services that are based in larger centres and have limited outreach capacity.
Combining resources has allowed access to high profile guest speakers and more dynamic programs.
Difficulties in collaboration
MHCB service providers mentioned they faced a range of difficulties in collaboration, including those listed here:
Most community and non government agencies are continually competing for the same Government funding resources. This creates a silo mentality within this service industry and therefore results in each agencies attempting to meet its own service agendas rather than looking at working together for the benefit of clients. Overall clients are only looking for who can help them; they are not necessarily interested in who is providing the service. Working together for the good of the client should lead to a more collaborative process between agencies, but because of the competitive nature of the funding it stifles this process.
If collaboration requires one service provider to take responsibility they are reluctant to share outcomes because of their own funding accountabilities.
Initially CAMHS was not receptive to our interest in working collaboratively We now work in a supportive way with CAMHS with shared clients. They provide counselling and we support the child at school and in the family environment and take steps to reduce their social isolation. Some aspects of support do not require degree level skills. However there is a real apprehension by clinical services to collaborate with staff members who have limited training regardless of the task.
A number of services [in other programs] have postcode or other boundaries which do not coincide with ours [and they cannot accept our referrals]. It makes service provision much more complicated than it need be, clients become frustrated and confused and sometimes it jeopardizes their progress as various family members are required to attend different services progress.
We would like to get more referrals from GPs because they are the first point of call for many clients with difficulties and we can take preventative action at the same time as any medical intervention, particularly if other family members are implicated.
- the funding and accountability requirements tend to create a silo mentality and some degree of competition between services for the same funds. This is not helpful for fostering collaboration:
- collaboration is time-consuming and so in resource strapped services it can be difficult to get time to put into collaborative work.
- a sense of 'turf' from health providers who do not want other services working in this area despite the very long waiting lists for young people and despite the high skill levels of staff we have (psychologists and social workers):
- trust building with services takes elapsed time and an understanding of the support we can provide. We now need to consolidate these relationships:
- Relationship building between services depends on the work of individuals. Collaboration is threatened by the high turnover of staff in all non-government organisations—due to low salary levels and short term funding contracts. It greatly affects productivity and client access to needed services.
- Postcode boundaries for a range of government funded programs complicate and hinder service provision:
- Historical patterns of service and referral structures do not take prevention and early intervention measures into consideration as well as they might:
Some other comments on difficulties were:
Different service boundaries and being based in different locations.
Turnover of staff both within our organisation and collaborating organisations.
Apprehension of clinical services to collaborate with staff members who have limited training.
Apprehension of other services to 'share outcomes' because of their own funding accountabilities.
Workforce issues
Some service providers said recruiting suitable staff was a problem, listing the range of reasons included in Figure 42.
Figure 42: Reasons for difficulties in recruiting suitable staff
Comments gave some amplification of the reasons shown above, for example:
The primary difficulty is the short term nature of employment in this sector. Again due to the funding arrangements by governments, most projects are short term (three years). It takes time to build the necessary competency and skills in staff and as they reach a high standard, the program terminates. At the moment the MHCB [Community Based Initiative] is under review and HP is in a difficult situation in trying to maintain the current staff until June 2010 without being able to give staff any indication of potential further funding. This impacts on the organisation's ability to forward plan and maintain staff and a high standard of service delivery.
The time limited funding of programs can cause recruiting or staff retention problems because staff need job security and plenty of notice if program funding is not likely to be renewed and alternative employment can be sought in a timely manner.
Suggestions on how to improve recruitment issues fell into two common themes:
- better wages through review of awards and greater comparability between government and community sectors and through increasing funding given to providers so that they can pay more;
- longer-term funding contracts and advance notice from FaHCSIA, the funding body, about the likely fate of contracts towards the end of their duration—this would provide greater certainty for staffing contracts.
Examples of comments reflecting these suggestions were:
Promote value of mental health and cost of mental illness to the community.
Profile ordinary individuals who work and contribute to their families and communities and who also have a mental illness.
Longer term funding agreements—5 to 10 years pending two yearly review.
Allowing up to 12 months lead time for orientation, training and developing and enhancing networks in the first year of the funding agreement. First year is about orientation, training, networking, setting up structures and processes, second year roll out, third year building on the second and evaluation, and so on.
Better Workforce planning for the mental health sector to have all workers within the sector skilled to perform at a certain standard for example, every worker holding a Certificate IV in mental health and funding offering the opportunity to staff to achieve this. In addition better succession planning within the mental health sector workforce.
Challenges in retaining staff
Salary levels and short-term contracts form the main impediments to retaining staff (Figure 43). Many interviewed resented this reality, as the following comments suggest:
This is hard work and we are very skilled—why can't we be paid the same as government workers?
I am moving to a government job next week and I will get $25,000 more for less effort. I regret leaving this job, it is really satisfying but I can't afford to stay.
Figure 43: Challenges in retaining staff for Mental Health Community Based Services
Poor retention rates have many negative consequences for organisations and their clients. The younger inexperienced staff have high training needs and require more supervision.
Complex clients have less opportunity to work with people who are highly experienced and skilled:
Supporting Adolescents and Families Tea. Need for large input of resources and time to recruit, induct train and skill large numbers of "entry level" inexperienced workers.
Young staff see the opportunity to work in NGOs as career enhancing and many have plans to use this experience to further their career in more highly paid positions.
I will always be grateful for the experience I have gained with this service. Not only have I had more responsibility than my peers who have government service jobs but I have also had to be involved in policy development and management which has been very challenging but good experience. If the contract for the service is not renewed, I know I will get a job somewhere else because of this experience. (staff member)
One challenge is to ensure that staff do not burn out due to the intense nature of the individual support offered to clients and the need for urgent intervention on a regular basis. The staff's willingness to go the extra mile to ensure that clients receive appropriate services when required often sees them planning out of hours work to facilitate best possible outcomes. Ensuring staff are not isolated but included will help.
Burnout is recognised as a constant risk with mental health services with providers noting that NGOs require and demand far greater input from staff, including with administration and policy development. Providing appropriate training to increase skills and cope with this extra work load is essential to avoid burnout. A number of staff mentioned they have had to cut back their working days so they could cope with job stress. This further disadvantaged them when compared with government workers.
Nature of staffing in Mental Health Community Based services
Services advised that services for young people and families require a high level of skills, particularly the work with families and the collaboration required with other services to achieve outcomes.
Figure 44: Most commonly held qualification level in Mental Health Community Based services
Accordingly, a high proportion of staff in MHCB services have a degree qualification. In service consultations it was clear that many degree staff also have certificate training in mental health, and additional certification in family therapy or other work related issues. As well, services usually require staff to have training in several areas such as mental health first aid, suicide prevention and keeping professional distance from clients. Many services had professional staff from other backgrounds such as teaching, health promotion, public health and nursing. Many such staff had additional professional qualifications in mental health, such as graduate diplomas or certificate courses.
Those services that were able to attract and retain staff had less disparity between the government and non-government sector awards. Some stated that it was their policy not to reduce salaries as a means of acquiring grants 'at any cost' as the work was demanding and required a cadre of staff with highly developed skills and experience. One service had an agency agreement with transparent salary structures from Aboriginal Health Worker, certificate trained staff, to social workers and psychologists. Both of these services had high staff stability illustrating the importance of salary levels in retention.
Methods of managing demand
Managing demand is a constant challenge for services (Figure 45). All except three of the services reported managing demand greater than they can supply. Not only does managing demand involve the capacity to make a rapid assessment of the urgency of the situation and devise an optimal management strategy but also to manage client time in the service.
The diagram below shows that the most commonly used methods of managing demand in excess of places available in Community Based Initiatives are referring potential clients to other services, dealing with the immediate crisis but deferring further assistance, and providing a partial service.
Figure 45: Methods of managing demand—Mental Health Community Based Services
Services have a clear understanding of the need to avoid client dependence on the initiative. The following comments represent how MHCB services manage client exit:
Clients are involved in the development of case plans and are encouraged to contribute to resolution of their identified issues. Ownership of outcomes is instrumental in early stages and capacity is built in problem solving through modelling and sharing if tasks and responsibilities After initial crisis is over encourage independence through providing information (or where to find information) and then allow clients to follow up themselves Provide information about other services which may support them especially support groups and local services which will be available long term. Reduce contact with clients allows them to utilise skills and knowledge they have to deal with issues that arise between contact.
Support and encourage the client to do as much as they can for themselves. Engage the client with other services and supports in the community to increase their knowledge of other services and increase their support system and social networks.
As part of the initial assessment when engaging with the service FMHSS27 workers aim to recognise participants strengths, support networks and potential referral pathways. Ongoing support is aimed at empowering participants and families with information and education to develop coping skills, enhance family communication and self care strategies with a focus from the start at working towards supporting the participant to managing the situation themselves.
The aims of the service are identified at the initial interview and the requirements of the participant identified. Once these goals have been achieved contact is reduced with the understanding further support can be obtained if the need arises. Strategies to resolve issues or manage problems are explored and participants are encouraged to make these changes themselves. Staff do not advocate on participants behalf but do provide support to access services or make complaints through appropriate channels if they feel they need someone with them. With successful outcomes, participants are generally more confident about resolving any further issues for themselves and managing difficult situations as they arise. We aim to build resilience, increase capacity to manage and empower carers to achieve better outcomes for themselves.
No service mentioned client dependence as a key ongoing issue and this is helped by the clients having developed skills and strategies and the sense of empowerment to use them. Clients also are connected to other supports and they know they can return if they experience new problems or need some refreshment of skills.
27 - Family Mental Health Support Service
Meeting the needs of priority target groups
Indigenous clients
Services which have been most successful in attracting and delivering services to Indigenous clients have usually had a long-established relationship with the relevant Indigenous community:
The auspice organisation has been providing services in the area for over thirty years and has gained the trust and confidence of the Aboriginal community. We attend the Aboriginal Inter-agencies. We have until recently employed a Koori Mentor (lost funding). We have a partnership with the Aboriginal Men's Group and Shell Harbour Aboriginal Council Youth Association. The service offered is flexible and tailored to the needs of young people and their families.
Marymead has an Indigenous Family Support Program. Horizons and the Indigenous program consult often regarding clients in their respective programs to determine how to achieve the best outcomes for families. Horizons program therefore may not regard Indigenous clients as formal clients if the Indigenous program is deemed to be best at delivering service.
Centacare has a strong history of engaging Indigenous communities, assisted by the employment of Indigenous staff that work diligently for acceptance and trust in local communities, provide leadership and cultural consultancies to other Centacare staff and the wider service network. Indigenous participants are supported through holistic approaches which include acknowledgement of the spiritual, emotional and family community connection, and history of displacement and multiple losses. Centacare's FMHSS currently has two Aboriginal workers who are based in their communities, and work collaboratively with other local organisations to ensure community acceptance of the program. FMHSS programs aim to be culturally appropriate and considerate of the communities in which they are delivered. The stigma and apprehension around mental illness and mental health in Indigenous communities has meant that the service has adopted the more culturally appropriate term 'social and emotional wellbeing' and concept of resilience in community awareness events. The service has also identified the Australian Torres Straight Islander Mental Health First Aid course as an effective and accepted way of breaking through the stigma that exists. The service has also recognised the benefit of supporting cultural traditions to improve social and emotional wellbeing of participants, including art workshops and overnight camps to reconnect with the land and country.
The most commonly cited action that services have taken to attract and service Indigenous peoples is networking and forming partnerships with organisations that provide services specifically to Indigenous people or that are Indigenous controlled:
Building relationships with services which specifically support the Indigenous Australians. We also ask if there are any specific needs and also refer to other relevant organisations, that is, Aboriginal housing. We have also done training in working with this group.
The second most cited action is employing Indigenous staff:
Entry level Indigenous Liaison officer recruited and supported by mentors in local community. Experienced caseworker provided services to clients through this liaisons worker who made initial contact with prospective clients. Family focused camps utilised to engage family groups in understanding mental health issues. Four-day camp provided for five families with a number of service providing information and resources in relaxed and non-clinical setting. Relationships and trust established with individuals with sessions provided on the importance of nutrition, parenting skills, domestic violence and mental Health awareness. Highly successful engagement strategy which resulted in follow up domestic violence support and engagement as individual client within case management model.
Have employed an aboriginal worker, Set up a group to reformat the smiles program for six to 12 years—Aboriginal case management training.
An Indigenous Mental Health Support Worker has been employed and has created his own networks within the Indigenous community. He is well respected and delivers a culturally sensitive service often within the community setting.
A number of services interviewed, however, were somewhat disappointed that they had not had a great deal of success in attracting many Indigenous clients, even though they had tried to collaborate with Indigenous agencies. Many of these services had been recently established and so have not had the opportunity to establish trust in Indigenous communities. The following responses illustrate the level of disappointment:
It is generally difficult to engage with Indigenous Australians. In the five Carers South Australia Carer Support regions many Indigenous Australians simply do not access services. Often if there is a situation/issue within an Aboriginal family that requires support, family groups will come together to provide support without linking with services. One of the key learnings from our Aboriginal Carer Support Program is that we will generally need to offer and provide support to the whole family, including and not limited to the Carer.
Lack of trust of agencies; cultural belief that families find their own solutions without external assistance; high level of need; longer duration of consultation required whilst meeting program requirements; data collection being culturally inappropriate.
The Tasmanian Aboriginal community is relatively small and fairly well funded; in the Launceston area aboriginal support workers are generally employed to support the local Indigenous population. Contact has been made with the Aboriginal community on Flinders Island but no requests have been made for support to date.
Many services cited challenges in meeting Indigenous community needs, as reflected in these comments:
Lack of an Indigenous worker; capacity to work with larger families; understanding of the implications of mental illness to the family.
The complex almost overwhelming set of needs that confront some Aboriginal families: death, imprisonment, drug and alcohol misuse, poverty, violence, child neglect, lack of formal education, lack of order in home, hygiene, hopelessness, the sense of dispossession in their own country, powerlessness.
Knowing how to win the confidence of that community. Having workers with knowledge of that community.
Fear and stigma associated with terms such as Mental Health and Mental Illness. Workload or community expectation placed on workers based in Aboriginal communities. Completion of FAHCSIA community and participant evaluations—workers needing to further support participants to complete lengthy surveys.
While a number of services saw the importance of having Indigenous staff some indicated it was not necessary, as they are actively delivering services to this group already. Indigenous staff also felt burdened by their depth of responsibility and often felt they were working outside of their competence levels.
Across Australia there are many examples of successful strategies. However to date there has been no avenue to capture this wisdom and to share it across the initiative.
People from a CALD background
A number of services have developed successful strategies to engage CALD communities but many still face challenges in doing so. Some catchment areas only have a few CALD communities and they are diverse making it very difficult to offer services that meet needs sensitively and comprehensively.
Comments from service providers reflecting this follow:
The program has 51 per cent participation of CALD families and so has successfully engaged this group though a number of effective strategies. We have employed two workers with community relevant languages. We have assertively and persistently interacted with a wide variety of CALD specific community groups and services and provided information in community languages. The Turkish community is one of the largest CALD groups in our catchment and we have successfully connected through consultation and advertising in Turkish language media and at events. We regularly use interpreters in most of our work.
We work in partnership with the Mental Health Promotion and Prevention Team who have a CALD Project Officer. This enables us to keep up to date on what needs are prominent in the CALD community. As part of this partnership we ensure that every education course and workshop we run has information on Transcultural Mental Health services and local CALD services. We have Mental Health brochures in CALD languages available and our courses advertising gets sent to local CALD Organisations. Our organisation also employed CALD staff.
We attend the Multicultural Services Network and the Multicultural Youth Services Network meetings. We also operate an early intervention service targeted to newly arrived young people and their families who have entered Australia in the past five years (specialist Reconnect). The service offered is flexible and tailored to the needs of young people and their families.
Working with the Migrant Resource Centre and the Phoenix Centre, also undergone comprehensive and varied training in working with the CALD community.
Language barriers and difficulty in accessing interpreter services—both because of availability in a catchment area and the cost of the services—were the most common difficulties experienced by service providers working with CALD clients. The lack of consistency of interpreters poses a barrier to quality service. As well, staff are concerned that lack of interpreter experience specifically in the mental health field may lead to poor integrity of communication.Concepts of mental illness and stigma associated with mental illness in many communities form other barriers which require skilled staff and tailored strategies. Services that have been funded to provide specific support to CALD groups have developed approaches which are highly suited to the communities served.
Comments from service providers follow:
Many of the newly arrived communities for example, African have a different concept of time management. Many are either working or going to learn English at TAFE (this is why we have targeted TAFE Queensland to work in collaboration with). Childcare is always a big challenge. Stigma around mental health in most CALD communities is very high and it is difficult to break down the barrier, particularly if there is strong religious beliefs about mental health within those communities. It continues to be a challenge to find the right worker within those communities who has a mental health background and strong connections and influence within those communities and is able to make a difference.
Many services reported difficulty in getting referrals for this client group and that migrant services seem reluctant to make referrals to them. The common theme in the comments was about committing the time necessary to collaborate and partnerships with appropriate organisations and to keep information in appropriate form available to potential clients for long enough to give them an opportunity to observe and check out the service and gain a degree of trust necessary for them to engage with the service.
Providing services for this group is resource intensive and challenging and not all services believe they have the capacity to support these clients.
One service reported that they have difficulty in getting enough referrals and that migrant services seem reluctant to make referrals to them. A common theme in the comments during interviews and in the survey was the difficulty committing the time necessary to continue collaboration and partnerships with appropriate organisations when collaborative activity is unfunded. It is also important to provide, and to keep, information in appropriate form available to potential clients for long enough to give them an opportunity to observe and check out the service and gain a degree of trust necessary for them to engage with the service.
Providing services for this group is resource intensive and challenging and not all services believe they have the capacity to support these clients.
Service capacity development
Most services had actively engaged with other services in education and collaborative skill development activities. The following quote representative a range of comments on this subject:
The service has planned, designed and delivered education skills development to groups and individuals on early intervention and mental health. Attendance at a variety of interagency meetings with a focus on mental health, sharing best practice, skill development and information. Basing a worker in a local High School a day each week for drop in, service provision and information. Provision of Mind Body Soul Workshops (relaxation and self esteem) at the Community Health for Adolescents in Need CHAIN Service.
Innovation and research
A total of 71 per cent of MHCB services said that they had contributed to evidence on early intervention and prevention and a number had engaged universities to conduct or support research into the effectiveness of service approaches. However, many innovative approaches are not well documented in a form in which they can be communicated more widely.
The following are examples of services' contribution to the evidence base on early intervention and prevention:
We are being researched by Monash university and NKC have done conference and workshop presentations at four conferences.
We were recently awarded a Certificate of Commendation for our programs in the early intervention and prevention category from the Mental Health Co Ordinating Council—All of our Mental Health First Aid Courses are specifically tailored for this, especially the Youth version—we have a lot of school teachers attend these courses which is fantastic as this is where our early intervention into youth mental health can be implemented. Parents and welfare staff also represent a large number of participants.—Our SMILES program again tailors to this category. The pre and post parent questionnaires of this course show evidence of effectiveness of this early intervention/prevention program—Our CBT course is an early intervention program for adults diagnosed with a mild to moderate depression. The idea of this program is to develop people's skills early thus preventing severe depression and or suicide ideation. Again the pre and post questionnaires of this course evidence a marked reduction in depression levels of participants.—Our Billabong Clubhouse workshops are specifically tailored to help prevent relapse.
We have contracted an independent evaluator to measure the wellbeing of participants who are new to the project and also those who have been receiving services for more than 12 months. This will help to assess the impact of Carers receiving services early in their Caring role versus those Carers who have been caring for several years without access to services.
Some of the responses to this question highlighted examples of innovative work which may be valuable to other services. The following comments illustrate this:
X has developed a rural engagement model of practice based on the successful MHCB program. The three stage model of stabilisation, resilience and social inclusion is applicable to many service arenas and is now being applied throughout the organisation as a whole that delivers programs right throughout the Riverina Murray.
We adapted the FaHCSIA survey to enable our children's groups and low literacy groups to understand the question. We did this through pictorial adaptations to each question.
Mental Illness Fellowship of Victoria has recently developed the Well Ways Duo program as a co-morbidity peer support education program presented by both consumer and carer facilitators. There have been many past requests for such a specific program.
SHINE has developed a range of engaging tools and strategies for working with children, families and schools. Demonstrated cost effectiveness of strengthening mental expertise in the secondary family service platform with staff able to work flexibly across the service system in universal and clinical settings.
This is the first time in Australia that the Behavioural Family Therapy Model has been applied outside of clinical mental health clinics. This is an innovative partnership between multiple services making use of each services expertise to provide an important service to families experiencing serious mental illness.
The program has an independent evaluation process attached being completed by the Psychosocial Research Centre, University of Melbourne. Program Staff have presented at forums such as (a) the MHS, the 19th Mental Health Services Conference at Perth, and (b) the Bouverie Family Centre Education program and had an article in the sector journal "The New Paradigm". The program also present to many services and organisations, sharing best practice around family work.
Issues arising for Mental Health Community Based Services
This Initiative is not visible to state and territory governments. While these levels of government might be aware of the parent service, particularly when the mental health component is attached to a large organisation, they are not aware of the contribution being made by FaHCSIA to mental health in the communities they serve, or to capacity building in the community and in other sectors.
Referring services such as PHaMs and MHR note there are not enough places for children and families who need them. They care for clients who are affected by family members with a mental illness who need interventions not only to prevent further problems but also to support the recovery of their clients
The research and evaluation component of the service contracts is not well understood and has been forgotten by some of the services visited. Some of the services visited are making serious efforts in evaluating the impact of their service on people and they have engaged universities to assist in this effort. In other cases the services are ill-equipped to research the impacts of their service and have made little headway in this regard.
The role of evaluation and research is not clear as FaHCSIA has no strategy to disseminate, and promote findings and it is left to services to undertake that sector capacity development in their region and to promulgate the findings through presentations to conferences, and through academics publishing their research. Many are actively undertaking this role but the results are not necessarily taken up strategically by FaHCSIA. While the MHCB initiative is clearly beneficial to the communities they serve, more would be achieved if there were more clarity of purpose and an organised approach to the collection and dissemination of evidence.
The need for collaboration with other services is well understood and exercised but like other programs the funding model does not take into account enough resources required for collaborative effort. Insufficient funds for travel so that outreach services can be provided means that the quality and efficiency of service provision is compromised.
Overall assessment of Mental Health Community Based Services Effectiveness
At the local level MHCB can be said to be a relatively high achieving intervention for the children and families able to access these services. However, because only 40 services are being funded across Australia the population effect of this effort is limited. However these services are contributing to the evidence base on prevention and early intervention as well as performing much needed support to children and families in which they are located.
MHCB is also making a significant contribution to community-based prevention of mental illness and early intervention where children and families are experiencing problems.
The most effective services are demonstrating the enormous potential of what can be achieved in the prevention and early intervention field. There are a variety of models and a number of the services have engaged universities to assist them to research the effectiveness of the interventions. For example, Marymead in the Australian Capital Territory and Wanslea in Western Australia are using the Children of Parents with a Mental Illness (CoPMI approach), Shine in Victoria is testing evidence developed by Queensland University, Southern Youth Services in New South Wales is using the RAFT model which was trialed by New South Wales Health with a particular emphasis on children and families who are homeless or at risk of homelessness. This has a number of characteristics similar to PHaMs.
Internationally, across many fields researchers have demonstrated that there is considerable payback for investment in early prevention and early intervention and there is considerable evidence that the mental health MHCB services are reaping sustainable benefits for children and families. It is also building the capacity of other services by being involved in training and in collaborative service development.
Collaboration with other agencies across the spectrum of need is generally well established with agencies reporting a range of relationships. Notably mental health services were an important referral source.
[ Top ]
B3. Snapshot of individual initiatives— Mental Health Respite Services
Objectives of the Mental Health Respite Initiative
The purpose of the Mental Health Respite (MHR) Initiative is to reduce the impact of mental health problems and mental illness on carers and their families. The initiative provides alternative or supplementary care arrangements, with the primary purpose of giving carers a short-term break from their usual caring role. This includes planned and unplanned respite.
Respite is perceived as:
- an outcome for carers (carers experience a short-term break from their caring role);
- a service for carers (carers receive a service appropriate to their needs);
- a service for the people for whom carers provide care (a care recipient receives a service appropriate to their needs).
Specific outcomes for MHR include:
- Carers have greater access to respite services tailored to meet their needs.
- Increased supply of mental health respite options.
Design of the MHR Initiative
The MHR Initiative provides flexible respite options for carers of people with severe mental illness/ psychiatric disability and carers of people with intellectual disability. There are two components:
- A brokerage service model provided across Australia in all Home and Community Care (HACC) regions using the existing network of Commonwealth Respite and Carelink Centres. The MHR brokerage component (MHR-BC) of the Initiative was implemented in April 2007 using a brokerage model enabling carers, the care recipient and their families to have the maximum choice and flexibility tailored to their specific respite needs.
- A direct funding model using the National Respite Development Fund (NRDF) to increase the availability (supply) of appropriate respite services through the MHRP, where limited service supply needs to be addressed.
The aim of the MHR-BC is to provide a flexible response to meet the individual needs of carers of people with severe mental illness/psychiatric disability and carers of people with intellectual disability for respite services.
The aim of the NRDF component is to identify and fund a range of flexible, innovative respite options for carers of people with mental illness/psychiatric disability and carers of people with intellectual disability that respond to the particular needs of the different regions across Australia.
Eligibility for service
Carers eligible to receive respite services include carers of people with mental illness/psychiatric disability; and carers of people with intellectual disability. Autism spectrum disorders are classified as an intellectual disability for the MHR-BC). The carer must be providing some form of regular care and the care must be assistance with the core activities of self-care, communication or mobility.
Service providers should give priority service to several groups of carers:
- elderly parent carers age 65 years and over (Indigenous carers are age 50 years and over) who live with and care for children (including adult children) with a severe mental illness/ psychiatric disability or intellectual disability;
- other non-residential elderly parent carers age 65 years and over (Indigenous carers are age 50 years and over) who are the primary carer of children (including adult children) with a severe mental illness/psychiatric disability or intellectual disability;
- carers of any age who care for people with a severe mental illness/psychiatric disability or intellectual disability who require emergency (unplanned) respite care;
- carers aged 55 to 65 years (Indigenous carers are age 40 to 49 years) who live with and care for children (including adult children) with a severe mental illness/psychiatric disability or intellectual disability.
Information sources
The following information is a compilation of interviews with 27 services, state and territory government representatives, peak bodies and the survey of MHR Service Providers. The survey was sent to 122 service providers and the response rate was 55 per cent. Of the respondents, 70 per cent were NRDF providers and 30 per cent Brokerage providers.
Our understanding of client views on the initiative was derived from interviews with more than 70 clients. These included face-to-face, telephone and small group interviews. Information was triangulated with information from case studies in the regular service reports routinely provided to FaHCSIA and interviews of mental health clients. Quotes from carers and mental health clients represent commonly expressed views and are illustrative of the major themes emerging through client interviews.
The Mental Health Respite Services in operation
Service types
MHR funds service providers to develop and deliver new innovative and flexible respite services and/or expand on existing respite services that meet the needs of the target group. The following examples are included in the MHR guidelines as the types of services that might be funded.
- centre-based: multiple care recipients with similar care needs engaged in supervised activities;
- in-home: where respite is provided in the carer/care recipient's house;
- host family: care recipient or group of care recipients are cared for in the home of a (paid or unpaid) respite worker;
- flexible respite: services that offer any combination of own home and host family/peer support respite;
- cottage day/or overnight: several care recipients with similar care needs are cared for in a home-like environment;
- recreational: where services focus on the care recipient being involved in community activities including one-on-one respite;
- peer support (recipient): peer run mental health and/or intellectual disability initiatives providing respite services for people with mental illness and/or intellectual disability;
- peer support (carer): peer run mental health and/or intellectual disability initiatives providing support to carers;
- troopie van: responsive respite service that provides respite without sending the care recipient out of their family (a vehicle and camping equipment is loaned to remote communities to enable them to provide bush respite for care recipients);
- care recipients camps: holiday care which runs for two or more days and provides care recipients with a positive experience in a supportive environment;
- education and training: specific projects funded to provide education/training to carers of people with a mental illness and/or intellectual disability to help them to maintain their caring role.
From interviews and the survey it was found that these approaches are represented variously around Australia.
Based on survey responses, the most common NRDF services included:
- provision of access to peer support group activities and recreational activities provided outside the home;
- periodic support in day-to-day activities, commonly more intensively to begin with then reducing as clients develop skills and methods of handling their carer role more effectively;
- case coordination, assisting the carer to access a range of services and assistance both for themselves and person for whom they are caring;
- education for carers, including programs to develop skills and resilience as carers;
- access to respite retreats and flexible respite options for carers such as occasional camps;
- in-home respite where respite is provided in the carer/care recipient's house, often on a regular basis.
The most common Brokerage services were:
- access to respite retreats and flexible respite options for carers such as occasional camps;
- in-home respite where respite is provided in the carer/care recipient's house, often on a regular basis;
- provision of access to peer support group activities and recreational activities provided outside the home;
- access to respite retreats and flexible respite options for carers such as occasional camps;
- case coordination, assisting the carer to access a range of services and assistance both for themselves and person for whom they are caring.
Client characteristics
In the service provider survey, services were asked what percentage of their carers (clients) fell into a number of possible target categories including Indigenous Australians, members of the Stolen Generation, people from a CALD background, Forgotten Australians, people who are homeless or at risk of homelessness, humanitarian entrants and non-familial carers.
The great majority of both NRDF and Brokerage services had no clients who were members of the Stolen Generation, Forgotten Australians or humanitarian entrants. However, it should be noted that many providers commented that they were unable to provide data for these categories because they are not required for FaHCSIA reporting.
Even though the majority of services had some Indigenous or CALD background clients, of these most had five per cent or fewer Indigenous clients as Figure 46 illustrates.
Figure 46: Percentage of Indigenous clients in MHR services
More MHR services had clients from a CALD background in slightly higher proportions than was the case for Indigenous people. Even so, the majority had 10 per cent or fewer clients in this category, as Figure 47 illustrates.
Figure 47: Percentage of CALD background clients in MHR services
Client perspectives on the MHR initiative
Client perspectives were gained by speaking with more than 70 clients in focus groups and in telephone interviews. This was combined with information gleaned from case studies and examples given by service providers. The following examples of benefits expressed by clients illustrate the range and complexity of cases and outcomes:
- services were responsive, respectful and empowering:
I kept on being told that services had waiting lists and I had to make do with bits and pieces of service. This is the first service I have had which has tried to find out my biggest needs and act on them first.
The fact that the service is there and I know I can call them has given me real peace of mind.
- reduction of stress creating the ability to continue caring for a client with a mental illness:
I was at my wits end. My son who has autism kept escaping and walking down the middle of the highway. I asked for support to repair the fence. I now have a new high fence and I don't have to watch him every minute. My neighbours are happy too. They have told me that they are less disturbed by the constant noise he makes now.
- more informed about mental health condition and development of skills in coping with the impact of a person with a mental illness on the family:
When I attended the course on recovery I gained a lot of hope and a sense that something could be done to help my parents, my brother and sister. My sister and I are working through the materials and taking steps ourselves. We know where to advise our family to go now. (Young woman aged 23)
Carers got in touch with me when my wife was hospitalised for eight weeks with depression. When my wife came home they came and cooked meals for the first couple of nights. Now they are teaching me to cook and I know enough to cook enough meals for half a week. I am very proud to be learning something new. It is a wonderful service. (Respondent aged 70)
The camp was really good. We were given information about mental illness and how to recognise signs of a relapse, stress management and time for relaxation too. I felt pampered and the meals were lovely. I was able to take my wife and she had activities during the morning so she was happy too. I feel much better able to cope now.
- assistance with getting the household in order because of the lack of time, emotional and logistical ability to keep on top of household affairs:
I was threatened with eviction as the house and yard was full of my husband and son's stuff. They both suffer from a mental illness. The service helped us clean it up. They brought a skip and took a lot of it away, and helped with a clean up. It was hard but we still have a roof over our head.
- assistance in connecting to needed services such as Centrelink and helping them resolve outstanding matters such as taxation, debt reduction:
I just couldn't keep up with paying bills and they cut my electricity off. I was too busy with my son to get away to do those things. The service helped me get it in order and put plans in place so it doesn't happen again.
- being able to have the time to attend to the needs of siblings or such as attend parent-teacher meetings or to take family members to appointments:
Everything changed when my son was struck down with mental illness. It is hard on all of us and my other kids miss out on my attention. When my son comes to the fishing group I try to do all the things I can't get out to do like take them to the doctor, by their school supplies or just have time to pay bills.
- reducing social isolation by linking clients to peer support networks:
Coming to this group has helped me keep myself sane. It is my time out. I've learned a lot too. (Carer)
- NRDF clients attending groups such as art and gardening spoke of their experiences in positive terms, noting that they were building confidence, for example, in riding a bike to the group, learning new things and as part of that realizing they had hidden skills:
I have sold a few of my paintings before the exhibition, which I am organising.
I hope to get back to work one day.
I have been asked to organise a film club with the peer support worker.
I have discovered that I really love fishing.
Yoga is wonderful. It has helped me deal with my anxiety. (Mental Health Clients of NRDF)
- continuing to work or study:
I can continue with part time work because a carer comes to be with my daughter an hour a day when my husband who looks after her when I am at work, to get to his shift work.
- reconnecting with family:
We have been coping with our two daughters with mental illness on our own for forty years and it has limited what we can do as a family. Recently my wife was assisted to visit her sister interstate whom she hasn't seen for over twenty years. That has meant so much to her. It is wonderful that someone has finally recognised the effort it takes and the personal costs.
Service provider perspectives on client outcomes
The outcomes for clients which services believe they have achieved are represented in Figure 48.
Figure 48: Outcomes for MHR clients
Service providers believed that services were providing much needed support for carers through the brokerage and supportive and meaningful activities for people with a mental illness. The outcomes they described mirrored what clients reported. Representative comments from service providers are outlined below.
The key outcomes that we are achieving are providing a high quality program that addresses the need of both carers and care recipients, that is flexible enough to deal with challenges that may arise.
Enhancing the capacity for families and carers to continue with their caring role whilst providing meaningful activities to people living with the symptoms of a mental illness.
By providing education to carers and care recipients we can reduce carer stress and burden and play a pivotal role in reducing the number of hospitalisations for the care recipient and the carer as a result of the caring role.
Assisting with social support for the recipient so that the carer is less stressed and linking them into other services. All carers want to see the person that they care for achieve some independence and with supports in place this can happen.
Assisting carers to have a break from their caring role.
Linking families and carers to carer supports and networks.
By providing information, referral, respite assistance and support to carers we foster resilience and knowledge as outcomes.
Building connections with people to their local communities in a way that supports sustainable relationships post respite episode.
Assisting people to build on their successes by providing new opportunities to participate in meaningful activities that support their own recovery based on what they have identified as important for themselves. New directions, interests, educational opportunities, improved sense of wellbeing and self esteem, skills, friendships, connections with own and local communities.
Our focus is on going beyond a limited one off or short-term respite effect (that does not provide hope for carers) so that they can envisage having a future without a significant carer burden.
Hope for the future, meaningful and enduring respite effects, opportunities for carers to be less isolated, enhance their informal network of friends and supports, go back to work, take holidays, enjoy a better quality of life for their family's crisis supports.
Assisting people to build on their successes by providing new opportunities to participate in meaningful activities that support their own recovery based on what they have identified as important for themselves. New directions, interests, educational opportunities, improved sense of wellbeing and self esteem, skills, friendships, connections with own and local communities.
Short-term emotional and physical respite. An opportunity to engage in other supports and self care. A rejuvenated carer role once respite has been implemented.
Reinforced importance of self care and permission to have time away from their caring role. Also reinforcement that respite is doable and achievable.
Providing a regular break from caring duties. Providing support for the carers over the phone on needs basis. Developing a trust relationship so that carers can confidently leave their loved one in our care.
The other significant outcome is that we are often able to support a person with mental illness to develop their own coping skills, informal supports and connections with community. This then provides a more enduring and long term respite effect for family members and carers.
Carers are pleased that their loved one with a mental illness has access to support and is achieving individually defined goals as part of their recovery.
About Mental Health Respite Services
Client numbers
Client numbers vary across service providers as shown in Figure 49. It should be noted that four of the services had more than 400 clients ranging from 436 to 800. These outliers are not included in the Figure.
Figure 49: Numbers of clients in MHR services
Brokerage services serve much larger numbers of clients than do NRDF services. This reflects the nature of the service with the former being much more short term and episodic than long term (examples include emergency arrangements, follow up with carers following acute care episodes with clients or providing much needed short-term support). The NRDF services provide more long-term support for clients with mental health problems (examples include interest groups for cooking, gardening, music, walking, and art). This provides social support, gradually restores confidence and develops skills.
Number of staff in Mental Health Respite Services
As illustrated in Figure 50, a total of 70 per cent of NRDF services had six or fewer staff, with the majority of the remainder of services having between seven and 12 staff. A very small number of providers had in excess of 20 staff. A total of 85 per cent of Brokerage services had six staff or fewer, with the remainder having between seven and 13 staff. The NRDF providers appear to use a larger number of part-time staff to meet the FTE requirements than the other programs.
Figure 50: Number of staff in MHR services
Developing collaborative service relationships and access to services through referrals
Clients have a range of needs many of which include a complex mix relating to social, economic, environmental and health. To respond to these needs, collaboration with a range of service providers is required. The range may include counselling, housing, Centrelink home maintenance and health services. Figure 51 illustrates the range of services which have referral and case coordination relationships with respite services by percentage.
Figure 51: Services that MHR services work with
Referrals and collaborative relationships form important avenues to link carers and people with mental health problems to needed services. While the spread of collaborative relationships is extensive, the percentages below demonstrate that the depth of these relationships is still quite shallow. Most service providers interviewed advised that the bulk of referrals are derived from:
- self referral (13 per cent NRDF and 18 per cent Brokerage);
- family members or friends (13 per cent NRDF and 8 per cent Brokerage);
- other respite services (15 per cent NRDF and 16 per cent Brokerage);
- State Mental Health Services (NRDF 23 per cent and 7 per cent Brokerage);
- GPs (NRDF 3 per cent and 2 per cent Brokerage).
This demonstrates that relationship building work is still in its infancy and that FaHCSIA MHR services do not yet have an adequately high profile with clients or referral agencies. This is consistent with the advice from the Australian Senate enquiry 'Who Cares?' which stipulates that only about 20 per cent of those in need receive a service. However, family and self referral figures indicate that word-of-mouth information about the service is a significant source indicating satisfaction by recipients with services received.
As well most state and territory government stakeholders had no or low awareness of the FaHCSIA MHR initiative so the referrals emanating from mental health services were largely as a result of the efforts of individual services.
Some commonly mentioned barriers to effective collaboration from the perspective of Respite service providers follow:
- Collaboration work is unfunded and time-consuming and so in resource strapped services it can be difficult to get time to put into collaborative work.
- The funding and accountability requirements tend to create a silo mentality and some degree of competition has developed between services for the same funds. This is not helpful for fostering trust or for willingness to engage in collaborative activity.
- Relationship building between services depends on the work of individuals and the building of trust over time. Collaboration is threatened by the high turnover of staff in all non-government organisations—due to low salary levels and short-term funding contracts. It greatly affects productivity and client access to needed services.
- A number of services have postcode or other boundaries which do not coincide with ours. It makes service provision much more complicated than it need be, clients become frustrated and confused when people are refused access to the most convenient service or one they have been using because they have moved. It jeopardizes their progress:
We (Rumbalaya) provide an aboriginal service which has a long history of providing services to aboriginal people in an extensive area crossing the Victorian and New South Wales border. The region we can serve with NRDF covers some but not all of that territory and includes additional areas which they are not traditionally associated with. Not all of aboriginal families in their traditional areas are able to access the service resulting in confusion and anger. Because family members are spread across this region it makes it even more difficult.
- Historical patterns of service and referral structures are based around medical interventions and are not set for prevention and early intervention measures:
We would like to get more referrals from GPs because they are in a position to pick up whether someone is in a caring role. They are the ones who can refer people early.
Brokerage and NRDF arrangements
The rationale for the development of the two-pronged approach to respite seemed to be that the Brokerage initiatives could be rolled out quickly while the NRDF was envisaged as a capacity building program, which was self sustaining as the MHR-BC services had funds to purchase the NRDF services provided. There was an expectation that the NRDF services would be used by the MHR-BC providers more than has occurred. However due to a range of factors the implementation of the initiative has not evolved as planned. Issues posed by an under-utilisation of NRDF capacity have been significantly resolved with a range of services under the NRDF component not also being funded through Brokerage to deliver mental health respite services.
However site interviews, survey responses and stakeholder interviews highlighted a range of continuing difficulties caused by the two-pronged approach to delivery of mental health respite services— MHR-BC and NRDF. These comments were borne out by the survey and by information from various evaluations conducted by providers and peak bodies.
Difficulties in the MHR-BC and NRDF models of mental health respite service delivery
The following issues were raised in the survey responses and in interviews:
- Unclear responsibilities/expectations of MHR-BC and NRDF services on each other (resulting in bickering, client confusion and longer time to achieve outcomes for client)—this issue was commonly raised by both NRDF and Brokerage providers.
- No or low referrals from local brokers (such as CRCC and Carers Support) was another issue raised by NRDF service providers:
Expectations by NRDF providers that we will fund all their respite, and their attitude that we are 'caretakers' of 'their' money (that is, Brokerage respite funding) but we broker many services depending on the needs and wishes of the carer/care recipient. (broker)
- Many Brokerage services claimed that many NRDF providers charged fees that were exaggerated:
Initially, these agencies [NRDF] expected us to fund the delivery of activities they wished to provide. This strained the relationship. We had very different understandings from FaHCSIA about how funds were meant to be spent. Mental Health providers were competing with each other, trying to develop similar and duplicating programs and wanting ongoing service provision to be paid for by us. There was a great deal of confusion.
- However some services claim that Brokerage services are not being realistic about the conditions of funding:
Some service providers had been providing services for people with disabilities and were completely new to the Mental Health system. Their approach reflects a rigid adherence to guidelines and meeting short term needs when we need flexibility to meet client needs and more long term assistance.
The brokerage providers were historically based on the disability model and they could not break away from that thinking that is, short term emergency care. This just does not suit the majority of carers of people with mental health problems.
- Brokerage service providers also raised difficulties experienced in establishing local NRDFs (namely, time, staff recruitment, identifying target groups, understanding client needs). Service relationships had been set up before they came on board.
- There were issues with the clarity of the guidelines and conflicting requirements posed by them:
At a local level the process of applying for brokerage funding when the brokerage services guidelines on carers' age criteria is conflicting with the NRDF guidelines.
Try as I might I could not comprehend how this program is supposed to work. (State health bureaucrat).
Despite the efforts of peak bodies and FaHCSIA to develop closer collaboration in many regions, misunderstandings and resentments remain. There are differing expectations of needs of clients and considerable variation in interpreting Brokerage guidelines across the country and within states and territories.
Benefits of current MHR-BC and NRDF arrangements
Importantly, most services saw some benefits arising from MHR-BC and NRDF arrangements and in some areas effective relationships had been developed at least between some NRDF providers and Brokerage agencies. The availability of funds to provide respite was the benefit most commonly identified by NRDF service providers while the variety of NRDF respite options available—that is, flexibility, and collaboration opportunities—were the next most commonly identified benefits by Brokerage agencies:
Some conflicts in guidelines can pose a problem, however usually the relationship works well and the process is relatively straightforward.
The NRD Funds are used to accept referrals from CCRC to provide respite to Carers within the funding criteria. We also have a service delivery component to improve access pathways for Carers. This Service Delivery allows for more Carers to receive Respite because of the savings made in direct funding rather than through 'double' assessment and middle management through the CCRC. We do have some referrals through the CCRC for short term Respite but we are able to provide longer term respite through the "Service Provision" funds.
Brokerage service providers most commonly commented on the greater availability of respite options, the opportunities for collaboration on flexible service options:
They are flexible and allow for creativity. The funding is adequate—unusual for respite programs and FaHCSIA is very reasonable and responsive in working with us to provide this program. The NRDF has allowed for some significant service delivery initiatives and this has already enhanced respite options for people in this region.
Suggestions on how the current MHR-BC and NRDF arrangement can be improved
NRDF service providers commonly identified that funding respite services should be handled through NRDF:
In Western Australia a robust, comprehensively evaluated consumer directed funding model operates in the disability sector. Funds allocated to carers of people with mental illness, which allow them to choose how they expend their funds would work well. Safeguards exist which enable the carer to 'shop' in the market place for the service provider or support of their choice. The service Provider must be an endorsed government provider. Once the family has chosen their support the funds are allocated to the agency who acquits expenditure. This model empowers families and also, over time, enhances the professionalism and quality of the sector.
Brokerage service providers commonly identified the need for increased funding and revision of the decision criteria for allocating funds.
Workforce issues
Most respite service providers advised that like other community managed services system, labour market and geographical factors posed constant hurdles to recruitment, retention and ongoing development of staff. Services reported pronounced adverse effects on the quality, consistency and sustainability of services. For combined Brokerage and NRDF services, 54 per cent reported that recruitment posed a problem. Of those who said recruitment was a problem, salary levels and short-term contracts were cited as significant factors. Rurality is also a problem to gain staff with appropriate skills and experience.
In the initial development phase of the NRDF program, the recruitment of a coordinator was a challenge. This was due to the position title, the part time role of the position, the geographical location and that the position was a non clinical role. However this challenge has been overcome. Currently we do not have any problems retaining staff due to the fact that the staff that are employed in the program also work across different programs within the organisation. However potentially if we do not receive referrals staff may look for more permanent work elsewhere.
In remote areas, we are often competing with the much higher paid jobs in the mining industry and to a lesser extent, with the government sector. We do not have a big choice in people applying for positions, and in some cases, it has taken us up to 9 months to fill positions. Wherever possible, we hire local people (a policy of wherever possible, employing local people, and also of not generally providing accommodation). This is resulting in a focus on employing more Aboriginal people which is a positive benefit of such policies.
Figure 52: Reasons for difficulties in recruiting suitable staff - MHR
Challenges in retaining staff
The common key issues in retaining staff for these services are the same as those experienced by other FaHCSIA Mental Health services. These include having to employ staff on short-term contracts with inadequate notice of continuation where the grant is renewed, and that of NGOs performing the role of training ground for early career staff as they cannot offer competitive salaries, conditions and career opportunities to satisfy workers for the long term. Geographical location forms another challenge, especially if it is associated with accommodation difficulties.Other issues which are emerging for Respite is that carer demand is unpredictable resulting in a similarly unpredictable workload for services. This makes it difficult to offer regular employment for some services.
Frontier Services tries to provide a supportive service to its staff who are all remote workers. Generally, it is wages that provide the biggest competition to us and people who may normally work as carers can often find work which pays up to three times what they would earn as carers.
In the initial development phase of the NRDF program, the recruitment of a coordinator was a challenge. This was due to the position title, the part time role of the position, the geographical location and that the position was a non clinical role. However this challenge has been overcome. Currently we do not have any problems retaining staff due to the fact that the staff that are employed in the program also work across different programs within the organisation. However potentially if we do not receive referrals staff may look for more permanent work elsewhere.
The Northern Territory has a high staff turnover due to transient population—many people come from the eastern and southern states or are in the military and do not intend to stay. Cost of living is very expensive in the Territory and a number of staff have commented on this. We also have a lot of travelers who don't have long term goals to stay in the Territory.
Limited scope within the Mental Health Respite Program for career advancement.
An issue for MHR-BC services in particular is the unpredictable nature of the demand for respite services.
Not being able to provide enough hours or competitive packages for Support Workers. For example, opportunities to establish a specific Aboriginal Program but didn't have the recurrent resources to employ a full time team leader to develop links with communities for referral and service provision; providing ongoing leadership to establish and maintain specific services particularly in some of the missions.
The greatest challenge that we have in retaining staff is the reduced numbers of carers being referred to the service. Without carers and carer recipients needing assistance as a service we cannot provide regular hours of employment to the staff as they are employed on a casual basis. As a result the only permanent staff member is the coordinator of the program and she is employed on a part time basis.
Spasmodic workload, unable to guarantee min hours per week for casuals—therefore non-permanent staff leave.
Nature of staffing in respite services
Staff qualifications
Figures 53 and 54 show that a moderate proportion of staff (27 per cent in NRDF and 62 per cent in Brokerage services) have degree qualifications, including those which incorporate exposure to mental health issues such as social worker, psychologist, or occupational health training. This, combined with the representation of Certificate courses, means that in many services there is a rich mix of staff. Degrees cover a range of fields including health related qualifications such as social work and psychology and nursing. Many services also have staff with post graduate qualifications covering mental health topics and other staff have certificates from mental health, disability and first aid courses. Comments provided on surveys showed us also that there are a number of services who have amongst their staff degree qualified staff in non-mental health or health fields such as social sciences and humanities.
Figure 53: Most commonly held qualification in NRDF services
Figure 54: Most commonly held qualification in Brokerage services
Quality of and access to services
Measures taken to assure quality of service
Of the categories offered in the survey, Figure 55 shows that quality control measures are more commonly informal (such as team discussions and training) rather than more formal (such as peer review and professional supervision).
Figure 55: Measures taken by MHR services to ensure quality of service
Services using professional supervision as a quality control measure were asked if the supervision was regular. The percentage of services with regular professional supervision were:
- 40 per cent for NRDF services; and
- 24 per cent for Brokerage services.
For special event counselling as part of professional supervision the results were:
- 40 per cent for NRDF services; and
- 33 per cent for Brokerage services.
These were supplemented by internal reviews and providing tools such as staff reporting requirements, checklists and quality improvement systems.
Meeting the needs of Indigenous people
Among the challenges experienced by services in meeting the needs of Indigenous people, the most common across both components was getting engagement and trust from Indigenous clients and their families. NRDF providers also identified being able to get access to transport services so that Indigenous carers could access services being able to work with the family rather as part of meeting care needs of the individual carer.
The Respite guidelines also limited what could be put in place for Indigenous people as they do not recognise members of extended families and the community had extended caring roles. As well, the concept of Carers and Respite services may be foreign to many groups. Examples of service provider views are listed below.
Major challenges include building trust, appropriate services to broker, staff recruitment for the centre.
As stated above, the makeup of an Indigenous family unit may not always be straightforward, that is, the family unit may actually be made up of several carers, without one being deemed the primary caregiver. Informally, it is known that an Indigenous family may struggle having another Indigenous worker.
There is a fundamental challenge in the FaHCSIA guidelines. Under the guidelines family members cannot be paid to provide care.
Yet in the Indigenous community everyone is related and is family. The white Anglo Saxon constructs don't sit comfortably with Indigenous constructs. The Indigenous community in this region is very small less than 0.6 per cent of the population. This population is made up of individuals from various traditional backgrounds that are not naturally connected so there is not one set of elders that represent all Indigenous people across the region.
Promoting the services to Indigenous carers can be difficult. The concept of respite is often not well understood amongst Aboriginal people, and often an Aboriginal client will have a number of carers on a community or similar. For many Aboriginal carers the idea that they have a right to access respite is difficult to grasp and it can take some time before carers will trust a service provider to work with the person they are caring for. Aboriginal people in remote communities can be highly mobile making it difficult sometimes to build up a relationship with a carer.
Preference to remain within their own communities; difficulty in forming meaningful liaisons with the service providers—they have had poor experiences of service providers / new staff, etc. Lot of funding in some agencies—no perceived need for carer services—different perceptions of what a 'carer' is.
This is an area where our Parent Organisation has identified a need to increase service provision to the overall Indigenous community not only in relation to the FaHCSIA— respite NRDF program but to all of the programs offered by Catholic Community Services. Unfortunately we have been unable to attract carers from an Indigenous background to access our program. Of the three carers currently using our program only one has identified themselves as being from an Indigenous background.
Throughout the region, we have observed that one of the biggest carer needs is for transport to get to activities etc. Our services often provide respite which requires taking the client(s) away for such activities as fishing, camping or to town for shopping.
The complex layers of disadvantage also reduce the capacity of Respite services to make a difference to a carer's life:
The most difficult challenges include: the complexity of needs of Indigenous carers, transient nature of Indigenous population, difficulty in identifying carer/s within the family. Time it takes to build relationships with the community before a service can be put in place.
Complexity of the needs of Indigenous Carers—extended family, housing, food—transient culture, difficulty to identify who is the carer—time available to build trust—complex needs of the family—Indigenous services to broker to—need for time out for the carer, being able to broker a carer break vs recipient.
Other system challenges:
There are quite a number of ATSI specific services in the LPA, and these services tend not to refer outside.
Successful strategies for serving Indigenous clients
The range of strategies used by respite services can be grouped as follows:
- promoting services to Indigenous groups/for which needs to be ongoing rather than on/off;
- employing/engaging Indigenous staff/workers with the right skills;
- partnering with relevant service providers/agencies;
- gaining a better understanding of Indigenous needs and including this in service delivery model.
Services which have been most successful in attracting and delivering services to Indigenous clients have usually had a long established relationship with Indigenous community and/ or have some Indigenous staff. The most commonly cited action that services have taken is networking and forming partnerships with organisations that provide services specifically to Indigenous people or that are Indigenous controlled and the second is employment of Indigenous staff, especially if they are from the local area. Comments from providers include:
- Engage Aboriginal workers in the program
- Improve networks with Aboriginal services
- Actively engage with Aboriginal communities, utilising existing networks within Anglicare or other partner organisations.
- Respecting cultural boundaries and assisting Indigenous carers on their terms.
At an organisational level we have an Aboriginal Service Development Coordinator who liaises with local Indigenous Interagency Meetings and Aboriginal communities on behalf of Catholic Community Services and provides information about available services. Continuation of this representation is vital as well as attendance of staff at NAIDOC celebrations throughout the year. We have developed our Aboriginal Strategy which aims to increase our numbers of Aboriginal staff by 2 per cent by 2011.We also provide Aboriginal cultural learning training to our staff to ensure they are culturally competent working with Aboriginal individuals.
At our Yorke Peninsula location we have initiated and developed a program at Pt Pearce an Indigenous community. We have worked with Indigenous Health service to establish a weekly art, craft, activities meeting including lunch in an appropriate setting in the community. This group is made up of some Carers, some people with intellectual and mental health disabilities. The group also has grandmothers and other community members participating. We have shown that once a program is instigated for the benefit of those with disabilities and their Carers the whole community will participate as a 'normal' gathering of people, all the while benefiting Carers and their 'cared for'.
Mind has linked in with Indigenous agencies and support networks to provide better access for Aboriginal clients. Assessments and services are undertaken with attention to cultural sensitivities and needs of clients and their families and communities. Mind's flexible approach to individualised respite is able to accommodate the needs of such clients suitably.
Developing a shared understanding of a 'care' within the Indigenous family structure and collectivist family care, establishing eligibility for NRDF services.
The IWCRCC has actively sought to meet with local ATSI service providers to gauge the needs if Indigenous carers. Most of our carers are Indigenous. Our services either have Indigenous staff or have been trained to work with Indigenous carers, including having access to Indigenous mentors, having completed training in cultural awareness and in how to make services culturally responsive SI workers from : Marrickville Council, IWACC, Redfern Community Health, Carers NSW and Centrelink. CRCC has also convened and established ATSI carers network to collaborate with ATSI service providers on how to support ATSI carers.
Most of our carers are Indigenous. Our services either have Indigenous staff or have been trained to work with Indigenous carers, including having access to Indigenous mentors, having completed training in cultural awareness and in how to make services culturally responsive.
Worked with 2 Indigenous co-ops in north of region; built in further liaison with the other regional co-ops; worked with major external Indigenous service provider to broker Indigenous specific respite. Presented the program to Indigenous service providers (especially HACC Co-coordinators); enhanced staff cultural awareness.
The IWCRCC has actively sought to meet with local ATSI service providers to gauge the needs if Indigenous carers, this has included meeting with ATSI workers from: Marrickville Council, IWACC, Redfern Community Health, Carers NSW and Centrelink. CRCC has also convened and established ATSI carers network to collaborate with ATSI service providers on how to support ATSI carers.
Formed an Indigenous CALD regional respite working party based on community development principles. Participants in this groups are Indigenous CALD Elders and there direct support service managers , HACC area manager, Community services manager or delegate, non Indigenous delegates, CR&CC SM, Centre Link Indigenous worker , Carers Qld CALD workers, Toowoomba Regional Council CALD Indigenous worker.
However, these strategies do not work for all. Many service providers have tried to establish relationships with Indigenous agencies but referrals have not been forthcoming and many agencies have had difficulty in recruiting Indigenous staff. There is a very low level of self referral by Indigenous people. Overall, there is a common understanding that service practices have to be tailored to support Indigenous carers that the services should be delivered in a culturally sensitive manner. It should also be noted that many Indigenous people are happy to access mainstream services. Some Indigenous people were interviewed as part of site interviews and they had found the service providers responsive and very helpful.
Meeting the needs of people from a CALD background
A number of services have developed successful strategies to engage CALD communities but many have found enormous difficulties in engaging CALD groups. In some catchment areas the communities are few or so diverse it is very difficult to be able to engage staff who can offer services which will meet the needs of different cultural groups sensitively and comprehensively.
Language barriers and difficulty in accessing interpreter services both because of availability in the area and the cost of the services were the most common difficulties experienced in providing services to CALD clients. The lack of consistency in having the same interpreter assigned to work with a client over time poses a barrier to good service. As well, staff are concerned that lack of interpreter experience in the field may lead to a lack of integrity in communication.
Concepts of mental illness and stigma associated with mental illness in many communities form strong barriers which require skilled staff and strategies tailored to each community. Services which have been funded to provide specific support to CALD communities have developed approaches which are highly suited to the communities served.
Comments from services follow:
Many of the newly arrived communities for example, African have a different concept of time management. Many are either working or going to learn English at TAFE (this is why we have targeted TAFE Queensland to work in collaboration with). Childcare is always a big challenge. Stigma around mental health in most CALDB communities is very high and it is difficult to break down the barrier, particularly if there are strong religious beliefs about mental health within those communities. It continues to be a challenge to find the right worker within those communities who has a mental health background and strong connections and influence within those communities and is able to make a difference.
Services advise that they have difficulty in getting enough referrals and that migrant services seem reluctant to make referrals to them. The common theme in the comments was about committing the time necessary to continue collaboration and partnerships with appropriate organisations and to keep information in appropriate form available to potential clients for long enough to give them an opportunity to observe and check out the service and gain a degree of trust necessary for them to engage with the service.
The CR&CC 28 has a CALD working group that has identified the CALD profile for the region and has developed an annual CALD plan for the service to ensure the service appropriately links with and supports CALD carers The Mental Health program has a CALD specific carer support worker who works with key CALD service providers to promote the program to various CALD communities in the region. When recruiting staff we have recruited people who are fluent in more than one language. The mental health program has staff who can speak Greek, Vietnamese Afrikaans and Chinese whilst Careline has staff who can speak Spanish, German, Polish, Russian, Italian and Yiddish. As well, CR&CC staff are trained in working with interpreters.
In addition coordinators have met with some services to provide information about the program and discuss potential needs and ways we can respond. Much more needs to be done in this area.
Very few of them—scattered—limited access to staff with language skills—paucity of regionally based interpreters—ageing communities.
Being able to broker to services that have workers that speak the specific language of the client. This can be very difficult. We usually have to have an introduction so that the client feels comfortable if there is a language barrier.
Some families and carers from CALD backgrounds are reluctant to accept a service even when it is evident that they are desperately needing support. Extra time and attention is taken to make sure families have information they need and that they understand the benefits respite can provide. Wherever possible Mind has attempted to provide support that is culturally relevant and that language barriers are addressed appropriately.
Very hard to engage as there are very few, across a large number of nationalities, spread across a large geographical region. Have worked with the regional Ethnic Councils and CALD support services.
Providing services for this group is resource intensive and challenging and not all services believe they have the capacity to support this type of client.
The turnover for translated materials is very slow. The activities we organise are often started before we can get the information back translated or find someone to translate. Finding the groups to access or activities they would be interested. We are not sure that expos are that successful.
There are a large number of different ethnic groups in the LPA but there are relatively few individuals within each group who tend to be spread over a large geography. Insufficient time for our respite coordinator to get out to market to these groups.
Some of the general challenges include issues such as language barriers, cultural understanding, beliefs and traditions and family trust. Our biggest challenge is meeting the CALD families needs and expectations.
Stigma is still held by many CALD groups re mental illness and carers may be reluctant to identify publicly. In addition the concept of respite is "foreign" to many groups some languages don't have an equivalent word for respite so it can be hard for some people to understand what respite is let alone use it.
28 - Commonwealth Respite & Carelink Centre
Successful approaches to meeting the needs of CALD clients
Examples from service providers were:
It has been an imperative focus to raise awareness of the Mental Health Respite Program within the CALD community, to address specific needs and provide appropriate support. The following are some of the steps we've made. Organised and facilitated two CALD carer retreats. Participated in the planning and facilitation of a Vietnamese mental health day event. Translation of flyers and pamphlets. Arranged a Chinese Health promotion day. Network continuously with bilingual workers and Transcultural Mental Health. Also attend meetings with multi cultural focus.
Mind employed a position to engage the CALD community with a community development focus. Respite has been promoted through several agencies supporting CALD communities and has a bilingual team member on staff.
Anglicare respite coordinators are involved in a range of regional forums that include representatives from CALD services.
Meeting the needs of CALD communities remains a significant challenge. CALD communities require similar approaches to Indigenous communities; taking the family needs into account, an understanding of the issues and sensitivities pertaining to the cultural group, the ability to communicate in a language other than English, and strategies which may need specific development. Servicing this group requires more time and resources than for English speaking groups.
Achievements of the Mental Health Respite Initiative
- There has been a net increase in the range of respite options available to carers in those HACC regions where funds have been directed;
- There has been an increase in service episodes for both carers and their family member suffering a mental illness;
- Carers using the services funded under the program report feeling better supported in their carer role;
- Carers using the services funded under the program reporting an improvement in their capacity to sustain their carer role;
- Carers participating in the program reporting improved knowledge about the respite options that are available to them.
Issues arising from current mental health respite policy and service design
Stakeholders report that policy and program design is too complex and does not allow a number of needs to be met. Most of the state and territory stakeholders reported either not knowing about the initiative or not understanding its structure and how it could be used effectively to support carers and form part of the care spectrum of government provided services. Most implementation issues seem to have arisen through implementation which was fast tracked. Some redesign and freeing up of service delivery arrangements will likely resolve many respite relationship issues.
Service delivery arrangements
The service delivery model—whereby the delivery of Mental Health Respite initiative is divided between Brokerage and the National Respite Development Fund—has been less than optimal. The idea that the two components would work in a complementary manner has been undermined by competition between each component, which has been exacerbated by differing mindsets on service priorities and delivery mechanisms. In particular, stakeholders claim that many Brokerage services which have operated through Australian Government Carelink Services have a disability client orientation and this has affected the orientation to care. Barriers to responsive and effective service delivery have emerged as a result.
Service providers report variation on the interpretation of the guidelines and great inconsistency in their application across Australia as a result. Views on the reasons from this include: some providers are over influenced by their history in administering disability services and apply that model without really understanding the need to apply different criteria for carers of those with mental health needs; the guidelines are unclear; and there is some distrust and competitiveness among providers within the sector because of the need to compete for funds.
Other issues and comments from interviews and site visits included the following points:
- On the whole NRDF service providers who were seeking support from Brokerage providers for carers of clients with mental health problems report difficulties with gaining the services they need.
- The two points of entry causes duplication of client assessment and clients express frustration at having to tell their story more than once.
- The orientation of Brokerage services was towards short term and emergency care and comprehensive carer support longer term care is not being provided.
- NRDF services reported that clients were having to having to wait too long with the result that they gave up seeking a service. Brokerage services were seen as gatekeepers. On the other hand they reported not having enough funds to meet demands. Some stakeholders felt this arrangement has in many places hampered service delivery.
- On the other hand MHR-BC services reported that NRDF services had unrealistic expectations of their newly developed service capacity being utilised and some reported that the services were too low quality or too expensive.
- The expectation at the inception of the NRDF grants that services become self sustaining was questioned. No respondent believed that this was possible although some cost recovery was possible.
Market penetration
Ensuring the service is taken up by those in greatest need is a continuing challenge. Contributing factors include the stigma associated with having a mental illness and the lack of self identification as a carer (many consider that their role is part of their family responsibilities). Lack of self identification is compounded by the lack of referrals from health professionals and mental health services (including GPs). This is further compounded by the current carer support eligibility forms which are oriented towards other forms of disability.
Difficulty in marketing to and providing appropriate services to Indigenous and CALD groups remains a continuing challenge with poor take up of services by these groups. These groups often have extended family arrangements and current policy guidelines do not provide enough flexibility to meet the needs of the extended family.
Eligibility
Eligibility for the initiative is too restrictive and many potential and needy clients do not have access to FaHCSIA's mental health services. Needy clients include:
- children who have parents with a mental illness;
- carers who are younger than 60 and who often have school age, dependent children or who are caring for siblings or relatives with a mental illness;
- carers who also have a mental illness;
- carers and people with mental health who live across service boundaries—this applied especially to extended family care arrangements and particularly affects Indigenous and CALD communities.
Eligibility currently includes those with a combined intellectual disability and mental health problems. The appropriateness of this is being questioned by providers. Services note that it is difficult to serve those two target groups as they require different systems of care and approaches to care and it is difficult to respond to both collectively. As well, services have a large demand from those with disability and this diminishes their capacity to build programs and services for those with a mental illness. While there is clearly a need to serve these dual conditions Respite service providers indicated that secondary advice and support for disability respite service providers, who provided more suitable structures and supports, would be a more useful than combining the two groups. As well, respite services for people with mental illness services are still in an early stage of evolution and much more assertive strategies need to be built to reach that target group.
Services note that if service approaches encompassed family oriented approaches to care they could be more responsive to the needs of all groups. For example a child of an adult with a mental illness may not be in a primary caring role but his/her life is greatly affected by their circumstance. As well, siblings of other children with mental illness need support.
Nomenclature
Services would prefer to drop the term 'respite' and instead use 'carer support'. Respite conveys associations of residential care and carers of people with mental illness do not usually see this as being relevant to their needs. Services noted that the restrictions on indirect respite (for example services that are not a substitute for carer provision but services that have the effect of respite, such as carer retreats, carer education, or counselling) should be lifted as such services were more useful to carers of people with a mental illness than traditional respite models.
Service capacity
Services to mental health clients need to incorporate a wide range of carer support which are not always available or accessible to carers. Evidence suggests that these should be oriented to long-term carer need. These include education about mental illness and psychosocial rehabilitation, time out for carers by either providing activities and programs for clients and/or providing assistance with direct care so they can be released for other activities. Services should be flexible to meet other support needs as households can be impoverished by the lack of ability of a carer to work because of caring responsibilities or to keep households running smoothly. There is some evidence that all these activities are occurring across regions but they are fragmented and a full suite is unlikely to be fully available for most clients.
Overall assessment of MHR effectiveness
The MHR initiative has served a large number of clients. The NRDF services seems to have been successful in attracting clients and providing a range of services for clients with a mental illness. However, the MHR-BC initiative seems to serve a disproportionately high level of clients who combine intellectual disability with mental illness. MHR-BC organisations have also had an orientation towards short term and emergency care and there is less need for these types of services for the MHR initiative. There is limited evidence on the best service models to apply in a range of situations and no benchmarks to compare assessments of the effectiveness of these services.
Through the FaHCSIA Respite Initiative significant capacity has been built up to deliver respite services to carers and clients who have a mental illness. There remains a significant challenge in ensuring that carers know about and use respite services and this capacity in a more coordinated way.
From the perspective of clients both service components have provided much appreciated services and they would like the Respite initiative to build its capacity even further.
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C. Schedule of consultations
| Organisation | State | Type of consultation |
|---|---|---|
| Richmond Fellowship of Western Australia Inc | WA | Site visit |
| Community First International | WA | Site visit |
| Ruah Community Services | WA | Site visit |
| Mission Australia | TAS | Site visit |
| Team Health | NT | Site visit |
| Red Cross | NT | Site visit |
| New Horizons | NSW | Site visit |
| Centacare (Catholic Care) | NSW | Telephone interview |
| Mission Australia | NSW | Telephone interview |
| Benevolent Society—Campbelltown | NSW | Telephone interview |
| Aftercare Penrith | NSW | Telephone interview |
| Aftercare Blacktown | NSW | Telephone interview |
| Southern Youth and Family Services | NSW | Site visit |
| Youth and Family Service | QLD | Site visit |
| Open Minds | QLD | Telephone interview |
| Eastern Access Community Health | VIC | Site visit |
| Karingal Inc | VIC | Site visit |
| Inner East Mental Health Service Association | VIC | Site visit |
| Mind Australia | VIC | Site visit |
| Uniting Care Wesley—PHaMs | SA | Site visit |
| Anglicare—PHaMs | SA | Site visit |
| Mental Health Foundation ACT—The Rainbow | ACT | Site visit |
| Organisation | State | Type of consultation |
|---|---|---|
| Richmond Fellowship of Western Australia Inc | WA | Site visit |
| Perth Home Care | WA | Site visit |
| Frontier Services | WA | Site visit |
| Anglicare Australia | TAS | Site visit / Telephone interview |
| Team Health | NT | Site visit |
| Carers Northern Territory | NT | Site visit |
| New Horizons | NSW | Site visit |
| Ontrack—Tweed Heads | NSW | Site visit |
| Benevolent Society—Hurstville | NSW | Site visit |
| Wheelchair and Disabled Association of Australia (House with no Steps) | NSW | Site visit/ Telephone interview |
| FSG Australia | QLD | Site visit |
| Blue Care (Uniting Church) | QLD | Telephone interview |
| Eastern Access Community Health | VIC | Telephone interview |
| Rumbalara Aboriginal Corporation | VIC | Site visit |
| Karingal Inc | VIC | Site visit |
| Mind Australia—NRDF | VIC | Site visit |
| CarerLink Barossa and Districts | SA | Site visit |
| Mental Health Foundation ACT—Marks Place | ACT | Site visit |
| Communities @ Work | ACT | Site visit |
| Organisation | State | Type of consultation |
|---|---|---|
| Silver Chain Nursing Association Mental Health Respite Program Centre | WA | Site visit |
| Family Based Care Association—Northern Region | TAS | Site visit / Telephone interview |
| Carers Northern Territory | NT | Site visit |
| Uniting Church in Australia Property Trust for Wesley Mission | NSW | Site visit |
| FSG Australia | QLD | Site visit |
| Carers Association | VIC | Site visit |
| Carers South Australia—Murray Bridge Respite Centre (Community Respite Carelink Centre) |
SA | Site visit |
| Carers ACT | ACT | Site visit |
| Organisation | State | Type of consultation |
|---|---|---|
| Community Link And Network (CLAN) Western Australia | WA | Site visit |
| Wanslea Family Services or Mental Illness Fellowship | WA | Site visit |
| Association of Relatives and Friends of the Mentally Ill (ARAFAMI) | WA | Site visit |
| Anglicare Australia—Family Mental Health Support Services | TAS | Site visit / Telephone interview |
| Aspire | TAS | Site visit / Telephone interview |
| Team Health | NT | Site visit |
| Danila Dilba | NT | Site visit |
| Ontrack—Tweed Heads | NSW | Site visit |
| Southern Youth and Family Services | NSW | Site visit |
| Youth and Family Service | QLD | Site visit |
| Mothers Against Drugs | QLD | Site visit |
| Multicultural Centre (Harmony Place) | QLD | Site visit |
| Drummond Street Relationship Centre | VIC | Site visit |
| Southern Family Life Services (SHINE Program) | VIC | Site visit |
| Odyssey House Victoria | VIC | Telephone interview |
| Carers South Australia—Supporting Carers of People with Mental Illness | SA | Site visit |
| Anglicare—Litmus | ACT | Site visit |
| Mary Mead—Horizons | ACT | Site visit |
| Organisation | Name | State | Type of consultation |
|---|---|---|---|
| Department of Health, Mental Health Division | Dan Hurley | WA | Telephone interview |
| Western Australian Association for Mental Health | Ann White | WA | Telephone interview |
| Multicultural Services Centre Western Australia | Ramdas Ransankan | WA | Telephone interview |
| Tasmania Mental Health Services (COAG contact) | John McCormick | TAS | Telephone interview |
| Mental Health Council of Tasmania | Ms Michelle Swallow | TAS | Telephone interview |
| COAG Mental Health Groups | Bronwyn Hendry | NT | Face to face interview |
| Northern Territory Mental Health Coalition | Phil Dempster | NT | Telephone interview |
| COAG Mental Health Groups | Vicki D'Adam | NSW | Face to face interview |
| Mental Health Coordinating Council of New South Wales | Jenna Bateman | NSW | Face to face interview |
| Multicultural Mental Health Australia | A Malak | NSW | Telephone interview |
| Multicultural Mental Health Australia | Georgia Zogalis | NSW | Telephone interview |
| New South Wales Southern Area, Inner West and Western Sydney Area Health Services Partnership Planning and New South Wales Mental Health and Drug and Alcohol Office, Clinical Partnerships Program |
Stephen Brand Barry Kinnaid Meg Griffiths Lynette Richards |
NSW | Telephone interview |
| COAG Mental Health Group Queensland | Renee Ryan | QLD | Face to face interview |
| Queensland Alliance Mental Illness and Disability Groups (Mental Health Peak Body) | Jeff Cheverton | QLD | Telephone interview |
| Chair of Brisbane South Division of General Practice | Dr Christine McAuliffe | QLD | Telephone interview |
| Mental Health Peak Body Contact | Paul Smith | VIC | Face to face interview |
| Psychiatric Disability Services Victoria (VICSERV) | Ms Kim Koop | VIC | Face to face interview |
| COAG Mental Health Contact | Gill Callister | VIC | Face to face Interview |
| Bushfire Victoria | Janie Davel | VIC | Face to face interview |
| St Vincent’s Hospital Melbourne | Evan Bichara | VIC | Telephone interview |
| South Australia Mental Health | Derek Wright | SA | Telephone interview |
| South Australia Social Inclusion Unit | Tania Dziadosz and Patricia May | SA | Face to face interview |
| Australian Capital Territory COAG Mental Health Groups | Richard Bromhead | ACT | Face to face interview |
| Department of Health and Ageing | Virginia Hart | ACT | Face to face interview |
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D. Mental Health Program Evaluation Advisory Committee
Membership comprised:
Chair-Manager, Mental Health and Autism Branch (FaHCSIA)
Group Manager, Community Engagement and Development (FaHCSIA)
The Mental Health Council of AustraliaThe National Advisory Council on Mental Health
Community Mental Health AllianceThe National Mental Health Consumer and Carer Forum (consumer and carer) Department of Prime Minister and Cabinet
Department of Health and Ageing
FaHCSIA Disability Policy and Coordination Branch FaHCSIA Homelessness Branch
FaHCSIA Family Relationship Services Branch
FaHCSIA Research and Analysis BranchFaHCSIA Mental Health Policy and Evaluation Section, Mental Health and Autism Branch
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E. Terms of reference
The evaluation of the mental health programs was to achieve the following outcomes to inform future developments in policy and program development:
- capture the impacts of the programs on individuals with a mental illness, their families and carers to date;
- capture what the programs have achieved individually and as a suite of community mental health programs;
- identify the synergies and alignment between the programs;
- seek to review the current service delivery models for each of the three programs and make recommendations on the way forward;
- consider the role of FaHCSIA's mental health programs within the broader mental health sector and how the suite of programs integrate and complement other services, with a specific focus on considering future policy direction.
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