Abstract
BackgroundCare coordination has been identified as a person-centred response to the difficulty in meeting the needs of people with severe and persistent mental illness and complex needs. This study evaluated the processes and outcomes of the Partners in Recovery initiative in the Australian Capital Territory, a program established to improve coordination of health and social care for this population.MethodsClient, carer and service provider experiences were investigated using a combination of quantitative and qualitative methods. Quantitative data were collected through questionnaires completed by clients (n = 25) and service providers (n = 14). Qualitative data comprised open-ended written feedback from the surveys, together with semi-structured interviews with selected clients (n = 6), carers (n = 2), and service providers (n = 4). In both study elements, questions focused on dimensions of experience such as communication, continuity and coordination, teamwork and sustainability. Descriptive statistics were calculated for quantitative data; qualitative data were analysed using content analysis.ResultsClients were satisfied with the program across the majority of experience dimensions, and there was evidence of improved access to coordinated care. Support Facilitators (care coordinators) were central to client and carer reports of the impacts of the program, and to coordination between services through connections built at the individual level. Challenges included difficulties with information continuity, a lack of role clarity for service providers, and uncertainty about the legacy of the program given the absence of formal agreements connecting different services.ConclusionsThe Support Facilitator role was critical to the success of the program. Support Facilitators acted as a source of stability and relational continuity for clients, while also enabling connections with external services through the development of individual level partnerships and personal networks. Systems level coordination was limited by communication difficulties and a lack of formalised infrastructure to support cooperation between services, calling into question the lasting impact of the program for system change.
Highlights
Care coordination has been identified as a person-centred response to the difficulty in meeting the needs of people with severe and persistent mental illness and complex needs
This paper reports system level outcomes from an evaluation of the Partners in Recovery (PIR) Program in the Canberra region, including client, carer and service provider experiences of improved partnerships between services, implementation of a local model of coordination and improvements in coordinated care
Evidence from clients, carers and service providers suggests that the PIR care coordination model is successful in meeting its aim to provide tailored, wrap-around care to people experiencing severe and persistent mental illness, but the success is driven by the Support Facilitators
Summary
Care coordination has been identified as a person-centred response to the difficulty in meeting the needs of people with severe and persistent mental illness and complex needs. Recent international reviews concluded that clients derived a sense of security and trust when they were told what to expect and were provided with information to support an active role in their self-management [6], and benefited from support when crossing care boundaries [7]. These studies suggest that both a personal relationship providing regular and continuous care, and encouragement of self-care management may underlie the success experienced via the care coordination model. Research on mental health care coordination programs that target these mechanisms is needed to understand the processes (including barriers and facilitators to implementation) and the outcomes for clients and services
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