Abstract
Introduction
Persons with severe mental illness [SMI] have multiple and complex needs which are beyond the scope of mental health services. As a result, they fall through the service gaps. The Partners in Recovery (PIR) initiative was set up by the Australian Government to improve care coordination between clinical and other supports to promote a community based recovery model for people with SMI. Gippsland Primary Health Network (PHN) was lead agency in Gippsland and has worked with Monash University to evaluate the initiative.
Practice change
The PIR initiative involved care coordinators who worked with clients to develop a care plan based on their unmet needs; then brokered services from relevant agencies in accordance with the plan and monitored change in needs over time.
Aim and theory of change
Needs listed on the CANSAS were aligned with those on Maslow’s hierarchy suggesting that when lower level physiological needs were met, it would be easier to meet higher level needs. Hence meeting accommodation and food needs would enable meeting other safety needs.
Targeted population and stakeholders
Adults with SMI in Gippsland were eligible for the initiative.
Stakeholders included consumers and carers, Gippsland Primary Health Network, community mental health services, mental health community support services and the Department of Health and Human Services.
Timeline
The initiative was implemented across Gippsland from May 2013 to June 2019.
Highlights
Care coordination was effective in significantly reducing the number of unmet needs among persons with SMI. When accommodation needs were met, needs related to money, childcare, food, safety to self, education and access to other services were also met.
Sustainability
Implementing this care coordination model was found to be cost-effective when compared to not doing so. However, sustainability is dependent on funding for the care coordinator role.
Comments on transferability
The model is simple and transferable because it does not require integration of service systems. Multiple agencies are able to work together for the benefit of the client without interfering with their system fidelity.
Conclusions
The PIR initiative was effective in reducing the unmet needs of persons with SMI in Gippsland.
Discussion
Implementing the PIR initiative in Gippsland benefited not only clients and carers but also service providers. It addressed an unmet service need for persons with SMI and demonstrated that addressing accommodation needs facilitates meeting other needs. A commitment from funders and government is necessary to enable these learnings to be incorporated into routine services.
The Fifth Mental Health and Suicide Prevention Plan and the deliverable of regional Mental Health and Suicide Prevention Plans, to be jointly developed by PHNs and Local Health Networks, provide a starting point for this to occur.
Lessons learned
Improved care coordination is necessary to address the multiple and complex needs of persons with SMI and needs to be incorporated into routine mental health services.
Addressing accommodation needs must be a priority for people with SMI as it facilitates the meeting of other needs.