An evaluation of an Australian initiative designed to improve interdisciplinary collaboration in primary mental health care
Introduction
Twenty percent of the Australian population will experience mental ill health each year (ABS, 2007), and mental disorders account for 24.9% of the disability burden in Australia (Begg et al., 2007). This high prevalence of mental disorders is echoed in other high income countries: the Centre for Disease Control and Prevention estimates that 25% of US adults have a mental illness each year (CDC, 2011), and the Mental Health Foundation estimates a similar prevalence rate for the UK (Mental Health Foundation, 2007).
Research has established the benefit of including psychological interventions in primary care treatment of common mental disorders (Gilbody, Bower, Fletcher, Richards, & Sutton, 2006), and primary mental health care is an essential component of mental health care provision in Australia. General practitioners, in particular, frequently provide an entry point into mental health care for high prevalence mental health disorders, creating the potential for early detection of mental disorders and appropriate referral pathways for ongoing care. Relevant to the provision of mental health services within the primary care sector is the growing evidence that collaborative mental health care further enhances treatment and is best practice (D’Amour et al., 2005, Rosenberg and Hickie, 2009). Collaborative mental health care involves not only the input of a number of different mental health care professionals in the care of a consumer, but also involves these professionals communicating and working together in collective action oriented towards a common goal (D’Amour et al., 2005). A recent review of 119 papers found strong evidence for the link between collaborative activities, positive clinical service delivery and economic outcomes (Fuller et al., 2011). Similarly, other researchers have found positive consumer impacts (van Orden et al., 2009, Zwarenstein et al., 2005).
Since the early 1990s, Australian National Mental Health Plans have emphasised the importance of joint planning, coordination of services and the development of links between providers across and within sectors in the delivery of mental health services. The 2009 Australian National Health and Hospitals Reform Commission emphasised that collaboration between support services was essential for recovery and individual self-determination, and many recent initiatives have consequently focused on linking primary care, specialist care and community-based services (Commonwealth of Australia, 2009). Despite this, the primary mental health care system has historically created a landscape wherein many professionals were operating in private practice settings in different locations and often working in professional ‘silos’ within their scope of practice (Davies Powell et al., 2006, McDonald et al., 2009).
Collaborative relationships do not happen instantly nor without considerable effort from all parties (Cook, 2005, Craven and Bland, 2006). Often co-ordinated leadership and external support are needed (Barker, Bosco, & Oandasan, 2005). In order to overcome barriers to collaboration within primary and community mental health systems, coordination of interactions between organisations and professionals needs to be reviewed (McDonald et al., 2009). In late 2006, Australia's public universal health insurance system (Medicare) introduced a primary mental health scheme, The Better Access to Psychiatrists, Psychologists and General Practitioners, known as ‘Better Access’. The Better Access initiative is one of 18 Australian Government initiatives introduced under the Council of Australian Governments (COAG) National Action Plan on Mental Health 2006–2011 (Australian Government, 2006). Better Access was introduced in response to low treatment rates for mental disorders, and aims to improve outcomes for people with such disorders by encouraging a team-based approach to their mental health care. The general practitioner (GP) is the first contact for people accessing primary mental health care; the GP may then treat the consumer him/herself or may refer the patient to other mental health care providers (Henderson et al., 2000). Better Access allows consumers referred to certain mental health professionals (eligible psychologists, social workers, mental health nurses and occupational therapists operating on a fee-for-service basis in private rooms) to claim a rebate (a set amount paid back to the consumer by the Australian Government) for their psychological care (Australian Government, 2006). Providers who work in the primary mental health care sector generally operate in private practices on a fee-for-service basis. Prior to the introduction of Better Access the fee was paid by the consumer and in some circumstances the consumer's private health insurance. Since the introduction of Better Access, this fee is paid by some combination of Medicare, the consumer, and, in some cases, the consumer's private health insurance.
The Australian Government's Department of Health and Ageing (DoHA) has carriage of the Better Access programme and has recognised that the programme creates potential for improved interdisciplinary collaboration. At minimum, GPs and mental health professionals are required to collaborate through the provision of the GP's written referral to the mental health professional, a mandatory written review and final report to the GP from the mental health professional, and a mandatory GP review of the patient after six sessions with the mental health professional. These minimal requirements for collaboration between the GP and treating clinician within the Better Access programme provide an ideal basis to foster more comprehensive collaborative interdisciplinary mental health care. Furthermore, in order for the GP to feel confident in referring their patients for quality mental health care, it is likely that they will want to meet and understand the expertise of those professionals to whom they are referring.
Despite this unique opportunity to build collaborative care in the primary mental health care sector, there is little information available regarding systematic attempts to foster collaboration between health professionals, and we still have limited understanding of the complexity of relationships between professionals (D’Amour & Oandasan, 2005). Some research describes attempts to improve interdisciplinary collaboration within or between organisations (e.g., Holleman et al., 2004, Kiesely et al., 2006, Michael et al., 2008), but none that we are aware of describe any attempts to improve interdisciplinary collaboration in a primary care setting at a national level.
The Mental Health Professionals Network (MHPN), a national initiative in Australia, undertook this monumental task. MHPN was funded by the Australian Government to bring together different primary care mental health professionals with the aim of fostering interdisciplinary networking, collaboration and ultimately improved consumer outcomes. MHPN was an innovative programme, as interdisciplinary teams are not common in Australian primary health care and collaborative care is made difficult by the boundaries between professionals and within health services (McDonald et al., 2009). This paper describes the evaluation of MHPN. The evaluation of MHPN, also funded by the Australian Government, sought to determine whether MHPN had been successful in fostering interdisciplinary networking and collaboration, and to provide formative feedback to MHPN (D’Amour & Oandasan, 2005).
The overall purpose of MHPN is to support the development of sustainable, interdisciplinary collaboration in the primary mental health care sector. MHPN has been responsible for promoting interdisciplinary collaboration and networking between GPs, psychologists, social workers, occupational therapists, mental health nurses, paediatricians and psychiatrists. It has done this through activity in three inter-related areas: facilitating interdisciplinary workshops supported by education and training materials; fostering ongoing, self-sustained interdisciplinary clinical networks; and hosting a website, web portal (MHPN Online) and a toll-free telephone information line which supported the programme. The underlying premise for MHPN's initial activities was that facilitated, interdisciplinary workshops would reinforce the importance of interdisciplinary collaboration and would enable relationships to develop between local providers. In turn, this would encourage participants to form ongoing networks comprising providers from a mix of disciplines. Support for both the workshops and the networks arising from them (e.g., via the website, MHPN Online and phone line) would therefore assist the networks to become self-sustaining.
MHPN's efforts have appropriately been conducted in inter-connected phases, which means that some of the above areas have received more attention to date than others:
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The initial establishment phase involved MHPN putting in place required personnel, governance mechanisms, infrastructure and resources across all three activity areas.
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In the delivery phase, MHPN placed considerable emphasis on rolling out workshops nationally. This involved a major push to recruit local mental health professional facilitators. Mental health professionals were invited to attend a workshop in their local area, and those operating in private practice were paid for their first attendance. Workshops usually involved facilitated introductions, a meal, a discussion of a case study of a client with a mental disorder, and a discussion of the possibility of generating an ongoing local network. MHPN aimed to conduct 1200 workshops nationwide before the end of June 2010 (30% in rural areas as required by the contract between MHPN and the Australian Government). The aim for each workshop was to have 20 registrations in order to find a balance between those registering but not attending and people attending without registering, whilst maintaining the ‘small group’ feel. Composition-wise, the attendees were to include at least three different types of mental health professions, and at least four GPs. The professions included were GPs, psychiatrists, paediatricians, psychologists, social workers, occupational therapists, mental health nurses and others where relevant.
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Towards the end of the evaluation period, MHPN moved into its sustainability phase. The focus of this phase was on generating ongoing networks of interdisciplinary mental health professionals from the workshop attendees with the aim of achieving improved interdisciplinary collaboration. Network co-ordinators guided the direction of the network and attended to logistical tasks associated with organising meetings. MHPN-appointed Network Sustainability Project Officers provided administrative support and guidance to the network co-ordinators. MHPN also made $500AUD funding available annually to each network to assist with costs such as venue hire, catering and payment of guest speakers. MHPN aimed for 70% of its workshops to result in the formation of ongoing, interdisciplinary, clinical networks that would meet regularly to discuss aspects of collaborative mental health care.
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Ultimately, MHPN is striving to reach a long-term phase. This phase will be characterised by improved collaborative care and better client outcomes in the primary mental health sector.
The Centre for Health Policy, Programmes and Economics (CHPPE) at the University of Melbourne was contracted by MHPN following a competitive tender process to undertake an independent evaluation of its activities from July 2009 to June 2010. This paper describes the evaluation in terms of its methods, findings and implications for the future directions of MHPN. The full evaluation report is available from the authors (Fletcher et al., 2010a). The current paper will discuss the achievement of some of these objectives in relation to workshop delivery, network formation, and sustainability and development of an online presence and community.
Section snippets
Method
Consistent with contemporary evaluation theory and practice, an objectives-based evaluation was conducted (Owen, 1999). CHPPE worked closely with MHPN to articulate a programme logic that would underpin the evaluation. This involved clarifying a hierarchy of objectives that reflected activities and desired outcomes. In general terms, the lowest level objectives related to the establishment phase, the intermediate level objectives related to the delivery phase, and the higher level objectives
Results
The results of the evaluation relate to the specific objectives outlined in the programme logic displayed in Fig. 1 and are presented here according to the area with which they relate (Fig. 2).
Discussion
MHPN successfully developed and ran an ambitious series of initial workshops which reached a significant number of mental health professionals from a range of disciplines who were working across Australia in both metropolitan and rural locations. The workshops were received positively by participants and generated considerable interest in the formation of ongoing, self-sustained, interdisciplinary clinical networks. MHPN established structures and processes to foster these networks, and
Conclusions
MHPN has successfully undertaken an ambitious project designed to promote interdisciplinary networking and collaborative mental health care. Few comparable initiatives have been conducted in mental health (Craven & Bland, 2006), and none has been undertaken in a primary care setting at a national level. The Australian primary mental health care setting was one wherein previously little interdisciplinary collaborative work was being undertaken. The changes to the government funding of mental
Acknowledgements
We would like to thank the Mental Health Professionals Network and the participants in this evaluation.
We would also like to thank the Commonwealth Department of Health and Ageing for funding the evaluation.
Justine Fletcher Justine is a Research Fellow in the Centre for Health Policy Programmes and Economics and psychologist. She works with the mental health team on various research projects related to national mental health initiatives, publishing in peer-reviewed journals and contributing to commissioned reports. Justine has run her own private practice and worked in various other clinical settings.
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Kylie King Kylie King is a Research Fellow. She is currently a part of the evaluation team for the Access to Allied Psychological Services component of the Australian Better Outcomes in Mental Health Care Programme. Kylie King is also a Psychologist with a background in Health Psychology. She has experience working in the public and private sector in direct service provision, secondary consultation, research, health promotion and community education.
Jo Christo Jo is a Registered Nurse with a keen interest in mental health. She has worked in the Centre for Health Policy Programmes and Economics as part of the mental health team. Contributing to research projects regarding national mental health initiatives and writing commissioned reports and peer-reviewed articles.
Anna Machlin Anna is a Research Fellow in the Centre for Health Policy, Programmes and Economics at the University of Melbourne. Anna currently works on a series of projects looking at the impact of media reporting of suicide on actual suicidal behaviour as part of the AHNRC capacity building grant The Australian Health News Research Collaboration. In the past Anna has worked on various evaluations of national mental health programmes. Prior to joining the Centre, Anna was employed by the Cancer Council Victoria where she worked on a range of projects, involving extensive data management and analysis as well as reporting to a range of government, international and not-for-profit organisations.
Bridget Bassilios Bridget Bassilios is a Research Fellow in the Centre for Health Policy, Programmes and Economics at the University of Melbourne; she has worked on a number of evaluations of mental health programmes. She is involved in qualitative and quantitative data collection, analysis and reporting. And has contributed to commissioned reports and peer-reviewed journal articles. She has supervised Master of Public Health research projects in mental health. She is also an independently practising psychologist specialising in depression and anxiety. She has had previous experience working in mental health across various public and private sector clinical settings.
Grant Blashki Grant is a Senior Research Fellow in the Nossal Institute for Global Health at the University of Melbourne, and a practising GP with a particular interest in mental health care. He is also an Honorary Senior Lecturer at the Institute of Psychiatry, Kings College London. He has published widely in the area of primary mental health care, has convened two conferences in general practice psychiatry.
Chris Gibbs As MHPN's CEO, Chris oversees all of the activities of the Mental Health Professionals Network. Chris has held significant leadership positions in the public health sector. He has undertaken roles at Melbourne Health and within both the Victorian Public Service and the community services sector. For 8 years, Chris was the Director of North Western Mental Health, one of the largest publicly funded providers of mental health services in Australia with a clinical workforce of 1300. Chris is currently Chair of VATMI Industries, a commercial business service employing 420 staff – 350 of whom have a disability. Chris commenced as CEO of MHPN in August 2008.
Angela Nicholas Angela is a psychologist and has worked for the Australian Psychological Society and the Mental Health Professionals Network. She has experience in the health and mental health fields conducting research and education. Angela's current focus is on professional writing.
Jane Pirkis Jane Pirkis is the Director of the Centre for Health Policy, Programmes and Economics in the Melbourne School of Population Health at the University of Melbourne. Jane has conducted numerous evaluations of national mental health programmes and policy developments. She was the lead author on reviews of the National Youth Suicide Prevention Strategy and the National Suicide Prevention Strategy, was contracted to co-write the National Mental Health Plan (2003–2008) and the Fourth National Mental Health Plan, and was involved in stakeholder consultations that formed part of the evaluation of the First National Mental Health Plan.