This study aims to identify and analyse examples of New Zealand mental health services that have successfully adjusted service provision to meet the “high and complex needs” of particular service users. The study aims to inform clinical staff, managers, planners and funders, service users and their whānau. The study involved identification of examples of innovative practice and integrated service delivery, identification and analysis of agreed critical success factors, and identification and assessment of at least 20 service users who have benefited as a result of those exampled innovative practice and integrated systems.
Purpose
This report provides information about mental health services in New Zealand that have successfully adjusted service provision to meet "high and complex needs" of some service users.
Methodology
Mental Health Commissioner, Dr Peter McGeorge, introduced the project to the national Mental Health Managers and Clinical Directors meeting in August 2009. Following this meeting, an invitation to participate, a participant information sheet, and consent form were emailed to general managers and clinical directors of DHBs and larger NGO mental health providers. They were asked to forward the email to the relevant service manager if they identified their service as one meeting the needs of service users who challenged their usual process of service provision. There were four responses to this request, one of which was an NGO.
The term “high and complex needs” was not defined in the information about the research, as this creates an additional data point given that each participating service made its own decision about whether they fitted the research criteria. This had the effect of broadening the inclusion criteria beyond diagnostic frameworks and allowed a comparison of participants’ understanding with the accepted clinical understanding of “high and complex”.
Data collection
The key criteria for services to be included in this study were that the service had a “high and complex” focus and that service users agreed that their care had met/was meeting their needs and helped them to live a satisfying life.
Achieving an adequate sample for this project took considerably more time than was anticipated. Later informal contact with the recipients of the recruitment email suggested a general reluctance on the part of DHBs to identify themselves as achieving extraordinary results. A final sample of three DHB services and five NGOs were included. These services are all based in the North Island.
Interviews took place with 16 staff members across the eight services. Of these, eight were in management roles and the remaining seven were in key worker/kaimahi roles. Of the key workers/kaimahi, four have formal health care qualifications at diploma level and beyond, and three have mental health certificates.
At least two service users from each service were interviewed. Each person was offered the opportunity to include whānau/support people in their interview. A total of 23 service users participated in the research. Only one whānau member opted to be interviewed. Of the 23 service user participants, there were 11 women and 12 men; 16 identified as European or Pākehā, three Māori and three Pacific. One person did not specify ethnicity. The ages of the service users ranged from 21 to 84 years, with the majority of participants being in the mid-20s to late 40s range.
Interviews took a semi-structured, open approach. Service user interviews focused on two questions: “Tell me about the care you are receiving” and “Why do you think your care has been a success?” Staff interviews included issues related to resourcing, philosophy of service, service parameters and staffing characteristics. Interview schedules are appended.
Key Results
Participating services indicated that they had set out deliberately to meet the needs of people whose needs had previously been unmet. They utilised change management processes, high-level support and adequate resources to meet needs.
Participating services prioritised interpersonal relationships and the management of the social determinants of distress. Indicators of success included the quality of the service user-carer relationship and progress towards the personal goals that were identified within that relationship. These indicators were supported by evidence of engagement with treatment and reduced reliance on inpatient or acute services. Clinical expertise was applied in support of meeting human needs for connection, housing and meaningful activity.
Participating services identified the differences between the needs associated with mental distress and the needs associated with loss of wellbeing and worked to provide a team of services and carers that could work effectively together. They gave priority to wellbeing, evidenced by the service user having their own safe place to live, meaningful activity, connection to friends and whānau, and someone who cared, to talk to about their mental distress.
Success factors for services identified in this study were:
- each person who comes into the service is viewed as having multiple needs in both wellbeing and distress that will require flexible intersectoral and intrasectoral responses
- successful services maintain a strong focus on stable housing, income and other basic human needs
- the priority is to work towards the connections and contributions people need in order to experience wellbeing; these are the services that take the lead role in co-ordinating care
- key workers – whether peer, clinical or support workers – are supported to develop sound, committed and loving relationships with the people they care for
- each service works from its own position of strength and does not attempt to be all things to all people
- all agencies and organisations that are involved in care meet regularly in person with the service user and support people
- expert clinicians act in support of the work towards wellbeing
- the sometimes tense relationship between clinical and peer or community support staff is brought to a point of mutual trust and esteem
- relationships between workers and management and among workers are viewed as important indicators of the organisation’s potential for success or failure and are carefully fostered
- trusting relationships with funders and planners are prioritised
- funding decisions that relate to particular service users are made at the grass-roots level, with the service user, their whānau and supporters, their key worker and the service manager
- when setting up or changing a service to reflect these changes, a change process is engaged with and change champions (people who will champion change) are employed.