Interagency collaboration in the context of services for individuals with severe and persistent mental illness (SPMI) refers to partnerships between clients, their carers, and families on the one hand and services such as those for mental health, primary care, general practice, employment, education, community health, and drugs and alcohol on the other hand. Although much has been written about the need for and usefulness of interagency collaboration (Ridgely, Lambert, Goodman, Chichester, & Ralph, 1998), implementation is challenging due to several factors (Rosenheck et al., 2002; Waghorn et al., 2012). The purpose of the current article is to highlight the potential of a care coordination model in promoting interagency collaboration using exemplars from the literature and lessons learned from Australia's Partners in Recovery (PIR) initiative.
Background: An Unmet Need
Individuals with SPMI experience symptoms severe enough to significantly impact their day-to-day activities for ≥2 years (Ruggeri, Leese, Thornicroft, Bisoffi, & Tansella, 2000). If individuals with SPMI are to recover, they must be able to feel a sense of autonomy and participate in normal day-to-day activities (Drake & Whitley, 2014). However, these individuals have multiple and complex needs. For instance, they frequently have difficulty accessing non–mental health services, such as housing (Jones, Reupert, Sutton, & Maybery, 2014), medical services (Chadwick, Street, McAndrew, & Deacon, 2012), and transport (Berren, Santiago, Zent, & Carbone, 1999). The inability to access these services results in poor health and social outcomes (Rosenheck, Resnick, & Morrissey, 2003) as well as increased attendance at emergency services (Lee et al., 2010). Difficulty in accessing services is due to the complexity of navigating different services and the stigma experienced by individuals with mental illness when accessing services (Isaacs, Sutton, Dalziel, & Maybery, 2017).
A recovery-oriented service system requires mental health services to work closely with clients and their caregivers, as well as with other agencies, such as housing, general practices, and welfare services. However, most mental health services are not designed to coordinate wraparound care for their clients (Berren et al., 1999). For instance, case managers in clinical mental health services who are traditionally responsible for care coordination are able only to point their clients to the relevant agencies that could address their various needs; they do not have the time to help clients navigate those agencies (Sutton, Isaacs, Dalziel, & Maybery, 2016). Due mainly to staffing shortages, the case manager's role in Australia has become restricted to medication and appointment compliance, risk management, and working with individuals in crisis (Sutton et al., 2016), giving case managers little time for recovery work. As a result, care for individuals with SPMI becomes fragmented and such individuals tend to fall through gaps in the system (Rosenheck et al., 2003).
To address these challenges, several attempts have been made to integrate services (Morrissey et al., 2002; Randolph, Blasinsky, Leginski, Parker, & Goldman, 1997). Service integration is possible in two ways. First, integration of services could be achieved at the service system level where there is collaboration in the way of doing business. Service system integration would involve practices such as joint service planning, setting up inter-agency agreements such as memoranda of understanding, information sharing, and joint service provision (Whiteford et al., 2014). Also referred to as service system integration, this approach is a top-down approach (Rosenheck et al., 2003). The second way of integrating services occurs at the service delivery level, where the needs of individuals are met with activities that do not alter the systems that provide these activities, such as in case management. This approach is a bottom-up approach (Randolph et al., 1997).
Factors Influencing Service System Integration
There are barriers to and facilitators of achieving service system integration. Mechanisms known to promote service system integration include formal interagency agreements, shared planning and staff training, shared case records, multiagency teams, and service co-location (Whiteford et al., 2014). Other factors that facilitate integration include streamlined communication, good leadership, mechanisms for monitoring partnership effectiveness, and early resolution of issues (Whiteford et al., 2014).
Barriers to integration include inadequate funding and technology (Whiteford et al., 2014), reluctance of staff to take on new caseloads (Hornby & Atkins, 2000), inability of services to share information due to the need to maintain confidentiality (Shepherd & Meehan, 2012), difficulty obtaining stakeholder buy-in (Whiteford et al., 2014), and different working hours and contact periods (Fredheim, Danbolt, Haavet, Kjønsberg, & Lien, 2011). In addition, developing a common understanding of a shared purpose and respecting others' roles and responsibilities are also recognized as challenges to service system integration (Whiteford et al., 2014). Hence, service system integration tends to be fraught with difficulties, as it involves agencies having to find a shared way of conducting business, which is particularly challenging when agencies have different work cultures and performance indicators.
Integration at the Service Delivery Level
Integration can also be achieved at the service delivery level when staff members from different agencies work together as a team. For instance, embedding mental health staff in welfare agencies has been shown to improve outcomes for homeless individuals with SPMI (Lee et al., 2010). The Assertive Community Treatment model, in which a psychiatrist, nurse, and case manager work together as a team, has been shown to reduce psychiatric hospitalization (Mueser, Bond, Drake, & Resnick, 1998). These exemplars, although narrow in scope, highlight the potential of integration at the service delivery level.
Care coordination is another example of integration at the service delivery level, which can improve quality of care and the relationship between care providers (Banfield et al., 2012). Care coordination has been recommended for improving quality of care when service system integration is not possible (Hansson, Øvretveit, & Brommels, 2012). Stewart, Wilson, Bergquist, and Thorburn (2012) describe the role of a dedicated care coordinator who helped improve mental health outcomes in an inpatient setting using a brokerage model. The care coordinator developed and maintained relationships between the service user, service provider, and other stakeholders who contributed to provision of care. Hence, the care coordinator served as a single point of contact between the service user and service provider and enabled a stronger therapeutic alliance for the client (Hopkins & Ramsundar, 2006).
The role of a dedicated care coordinator has also been shown to be successful in community settings. A care coordinator (known as a support facilitator) was central to Australia's PIR initiative (Australian Government Department of Health, 2016). The PIR initiative was designed to change the focus of mental health care for individuals with SPMI from a clinical approach to a more holistic approach, with emphasis on addressing non-clinical and social needs. The aim of the initiative was to improve partnerships between agencies and promote a better integrated mental health care system (Isaacs et al., 2017). The outline of the care coordination model used in Australia's PIR initiative is displayed in Table 1.
Description of the Care Coordination Model of Australia's Partners in Recovery (PIR) Initiative
Support facilitators (i.e., care coordinators) of the PIR initiative also used a brokerage model, bringing different service providers together to serve as the care team for the client. After the client listed his/her needs and priorities, the care coordinator worked with the client and other members of the care team to develop a care plan. Each team member (i.e., service provider) was responsible for delivering his/her component of the plan (Isaacs et al., 2017). This model is client-driven in that the client (or caregiver, in cases of clients who are unable to make decisions) drives the type of care with the help and support of the care coordinator. Service providers withdrew from the care team when the client no longer needed their services. At the same time, new providers joined the team to address newly identified needs (Isaacs et al., 2017). Regular meetings of the care team ensured that all service providers were on the same page as the client and care coordinator (Figure 1). As a result, multiple sectors and agencies were involved in the provision of individualistic care without the main challenges of service system integration, such as the inability to share information and difficulty developing a common understanding of a shared purpose. Furthermore, the PIR initiative did not need formal interagency agreements, shared case records, or service co-location, and appeared to be cost effective (Isaacs, Dalziel, Sutton, & Maybery, 2018). The total cost of providing the service for one consumer per year (set-up and ongoing) was estimated to be 15,755 Australian dollars, and the ongoing cost per year was estimated to be 13,434 Australian dollars. Costs of hospitalization, residential psychiatric care, unemployment benefits, prison, and homelessness far outweigh the cost of this service (Isaacs et al., 2018).
Visual representation of a care coordination model.
Implementation of the Partners in Recovery Initiative
Although the care coordination model represents a bottom-up approach, it requires a system change toward a more collaborative way of working. This system change requires someone to be involved in building networks and working relationships between agencies—a role that has been referred to as boundary spanner (Williams, 2002). The role of the boundary spanner needs to function successfully if a new care coordination program is to take root. Boundary spanning is the responsibility of the auspice agency (Brophy, Hodges, Halloran, Grigg, & Swift, 2014). The PIR initiative undertook the function of boundary spanning by using advertisements on the local radio and television as well as posters at key locations.
Nonetheless, care coordinators also had to promote the initiative by presenting it to local services, attending local forums, and contacting service providers through telephone calls and e-mails. Presentations and repeated discussions at team meetings of local area mental health services were necessary to allay the fears and suspicions of mental health clinicians and case managers who initially believed that their roles were being usurped.
Care coordinators need to have administrative and social skills as well as an understanding of local services. The role of care coordinator is to be a single point of contact for all stakeholders and be able to assist clients with becoming self-reliant. Further details about the role and competencies of the care coordinator in Australia's PIR initiative are published elsewhere (Sutton et al., 2016).
Inadequate training in care coordination was also a problem in some areas, particularly when care coordinators joined the initiative after training programs had already been completed. This problem was overcome by taking ownership of the initiative and being proactive, as well as by ensuring clear, consistent, and respectful communication to referrers and care team members.
There was also an initial lack of acceptance of care coordinators who were from culturally and linguistically diverse backgrounds. However, strong support from their employers, valuing and acknowledging the contributions of care team members, and documentation of client progress and care team member contributions enabled acceptance. Care coordinators who were not from the local area lacked knowledge of local services and work culture. These individuals received support from individuals who already had well-developed networks from previous experience in the sector.
Undoubtedly, the model required a paradigm shift from existing referral practices, but ultimately resulted in a better understanding and awareness of clients' needs (Cheverton & Janamian, 2016). Service providers' opinions are generally a good indicator of the usefulness of services and on-the-ground realities (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). In a qualitative study of the care coordination model, service providers indicated that a team approach to client care had met longstanding unmet needs, and that the model enabled better interagency collaboration (Isaacs et al., 2017). Use of a care coordination model in a recovery-oriented service system is relatively new, and effectiveness studies of this model have yet to be undertaken.
Conclusion and Implications
In providing recovery-oriented services for individuals with SPMI where interagency collaboration is paramount, a model of care coordination has the potential to enable services to work together to achieve client goals. Care coordination models are client-driven, have the potential to produce good client outcomes, and can overcome challenges that preclude service system integration.
A care coordination model is feasible and appropriate in most developed nations, and its implementation has the potential to overcome the challenges of recovery-oriented services designed for individuals with SPMI. Empirical studies are likely to demonstrate the benefit of care coordination models for clients and usefulness for interagency collaboration. Evidence-based recovery-oriented models of care for individuals with SPMI are in the process of major reform, and psychiatric–mental health nurses are well placed to drive this change.
- Australian Government Department of Health. (2016). Partners in recovery: Coordinated support and flexible funding for people with severe and persistent mental illness with complex needs (PIR). Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/content/mental-pir
- Banfield, M.A., Gardner, K.L., Yen, L.E., McRae, I.S., Gillespie, J.A. & Wells, R.W. (2012). Coordination of care in Australian mental health policy. Australian Health Review, 36, 153–157. doi:10.1071/AH11049 [CrossRef]
- Berren, M.R., Santiago, J.M., Zent, M.R. & Carbone, C.P. (1999). Health care utilization by persons with severe and persistent mental illness. Psychiatric Services, 50, 559–561. doi:10.1176/ps.50.4.559 [CrossRef]
- Brophy, L., Hodges, C., Halloran, K., Grigg, M. & Swift, M. (2014). Impact of care coordination on Australia's mental health service delivery system. Australian Health Review, 38, 396–400. doi:10.1071/AH13181 [CrossRef]
- Chadwick, A., Street, C., McAndrew, S. & Deacon, M. (2012). Minding our own bodies: Reviewing the literature regarding the perceptions of service users diagnosed with serious mental illness on barriers to accessing physical health care. International Journal of Mental Health Nursing, 21, 211–219. doi:10.1111/j.1447-0349.2011.00807.x [CrossRef]
- Cheverton, J. & Janamian, T. (2016). The Partners in Recovery program: Mental health commissioning using value co-creation. Medical Journal of Australia, 204(Suppl. 7), S38–S40. doi:10.5694/mja16.00124 [CrossRef]
- Drake, R.E. & Whitley, R. (2014). Recovery and severe mental illness: Description and analysis. Canadian Journal of Psychiatry, 59, 236–242. doi:10.1177/070674371405900502 [CrossRef]
- Fredheim, T., Danbolt, L.J., Haavet, O.R., Kjønsberg, K. & Lien, L. (2011). Collaboration between general practitioners and mental health care professionals: A qualitative study. International Journal of Mental Health Systems, 5, 13. doi:10.1186/1752-4458-5-13 [CrossRef]
- Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P. & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review and recommendations. Milbank Quarterly, 82, 581–629. doi:10.1111/j.0887-378X.2004.00325.x [CrossRef]
- Hansson, J., Øvretveit, J. & Brommels, M. (2012). Case study of how successful coordination was achieved between a mental health and social care service in Sweden. International Journal of Health Planning and Management, 27, e132–e145. doi:10.1002/hpm.1099 [CrossRef]
- Hopkins, M. & Ramsundar, N. (2006). Which factors predict case management services and how do these services relate to client outcomes?Psychiatric Rehabilitation Journal, 29, 219–222. doi:10.2975/29.2006.219.222 [CrossRef]
- Hornby, S. & Atkins, J. (2000). Collaborative care: Interprofessional, interagency, and interpersonal. Oxford, UK: Blackwell Science. doi:10.1002/9780470693858 [CrossRef]
- Isaacs, A.N., Dalziel, K., Sutton, K. & Maybery, D. (2018). Referral patterns and implementation costs of the Partners in Recovery initiative in Gippsland: Learnings for the National Disability Insurance Scheme. Australasian Psychiatry. Advance online publication. doi:. doi:10.1177/1039856218759408 [CrossRef]
- Isaacs, A.N., Sutton, K., Dalziel, K. & Maybery, D. (2017). Outcomes of a care coordinated service model for persons with severe and persistent mental illness: A qualitative study. International Journal of Social Psychiatry, 63, 40–47. doi:10.1177/0020764016678014 [CrossRef]
- Jones, R., Reupert, A., Sutton, K. & Maybery, D. (2014). The interplay of rural issues, mental illness, substance use and housing problems. Journal of Mental Health, 23, 317–322. doi:10.3109/09638237.2014.951476 [CrossRef]
- Lee, S., Castella, A., Freidin, J., Kennedy, A., Kroschel, J., Humphrey, C. & Kulkarni, J. (2010). Mental health care on the streets: An integrated approach. Australian and New Zealand Journal of Psychiatry, 44, 505–512. doi:10.3109/00048670903555120 [CrossRef]
- McDonald, K.M., Sundaram, V., Bravata, D.M., Lewis, R., Lin, N., Kraft, S.A. & Owens, D.K. (2007). Care coordination (Vol. 7). In Shojania, K.G., McDonald, K.M., Wachter, R.M. & Owens, D.K. (Eds.), Closing the quality gap: A critical analysis of quality improvement strategies. Rockville, MD: Agency for Healthcare Research and Quality.
- Morrissey, J.P., Calloway, M.O., Thakur, N., Cocozza, J., Steadman, H.J. & Dennis, D. (2002). Integration of service systems for homeless persons with serious mental illness through the ACCESS program. Psychiatric Services, 53, 949–957. doi:10.1176/appi.ps.53.8.949 [CrossRef]
- Mueser, K.T., Bond, G.R., Drake, R.E. & Resnick, S.G. (1998). Models of community care for severe mental illness: A review of research on case management. Schizophrenia Bulletin, 24, 37–74. doi:10.1093/oxfordjournals.schbul.a033314 [CrossRef]
- Randolph, F., Blasinsky, M., Leginski, W., Parker, L.B. & Goldman, H.H. (1997). Creating integrated service systems for homeless persons with mental illness: The ACCESS Program. Psychiatric Services, 48, 369–373. doi:10.1176/ps.48.3.369 [CrossRef]
- Ridgely, M.S., Lambert, D., Goodman, A., Chichester, C.S. & Ralph, R. (1998). Inter-agency collaboration in services for people with co-occurring mental illness and substance use disorder. Psychiatric Services, 49, 236–238. doi:10.1176/ps.49.2.236 [CrossRef]
- Rosenheck, R.A., Lam, J., Morrissey, J.P., Calloway, M.O., Stolar, M. & Randolph, F. (2002). Service systems integration and outcomes for mentally ill homeless persons in the ACCESS program. Psychiatric Services, 53, 958–966. doi:10.1176/appi.ps.53.8.958 [CrossRef]
- Rosenheck, R.A., Resnick, S.G. & Morrissey, J.P. (2003). Closing service system gaps for homeless clients with a dual diagnosis: Integrated teams and interagency cooperation. Journal of Mental Health Policy and Economics, 6, 77–87.
- Ruggeri, M., Leese, M., Thornicroft, G., Bisoffi, G. & Tansella, M. (2000). Definition and prevalence of severe and persistent mental illness. British Journal of Psychiatry, 177, 149–155. doi:10.1192/bjp.177.2.149 [CrossRef]
- Shepherd, N. & Meehan, T.J. (2012). A multilevel framework for effective interagency collaboration in mental health. Australian Journal of Public Administration, 71, 403–411. doi:10.1111/j.1467-8500.2012.00791.x [CrossRef]
- Stewart, M.W., Wilson, M., Bergquist, K. & Thorburn, J. (2012). Care coordinators: A controlled evaluation of an inpatient mental health service innovation. International Journal of Mental Health Nursing, 21, 82–91. doi:10.1111/j.1447-0349.2011.00771.x [CrossRef]
- Sutton, K., Isaacs, A.N., Dalziel, K. & Maybery, D. (2016). Roles and competencies of the support facilitator in Australia's recovery-oriented mental health initiative: A qualitative study from Gippsland, Victoria. Australian Health Review, 41, 91–97. doi:10.1071/AH15183 [CrossRef]
- Waghorn, G., Childs, S., Hampton, E., Gladman, B., Greaves, A. & Bowman, D. (2012). Enhancing community mental health services through formal partnerships with supported employment providers. American Journal of Psychiatric Rehabilitation, 15, 157–180. doi:10.1080/15487768.2012.679582 [CrossRef]
- Whiteford, H., McKeon, G., Harris, M., Diminic, S., Siskind, D. & Scheurer, R. (2014). System-level intersectoral linkages between the mental health and non-clinical support sectors: A qualitative systematic review. Australian and New Zealand Journal of Psychiatry, 48, 895–906. doi:10.1177/0004867414541683 [CrossRef]
- Williams, P. (2002). The competent boundary spanner. Public Administration, 80, 103–124. doi:10.1111/1467-9299.00296 [CrossRef]
Description of the Care Coordination Model of Australia's Partners in Recovery (PIR) Initiative
Components of a Care Coordination Model (McDonald et al., 2007)
Care Coordination Model of Australia's PIR Initiative (Isaacs et al., 2017; Sutton et al., 2016)
|Setting up the model of care and tasks
The unit of implementation is a geographic region governed by a regional health-planning organization through which federal funding is disbursed
A consortium of clinical and non-clinical service providers are instituted who will support the model under the auspices of the regional health-planning organization
Non-clinical mental health community support non-governmental organizations are designated as care coordination agencies according to regional load
Care coordinator agencies appoint care coordinators according to expected number of clients (seven to 10 clients per care coordinator)
Referral and other protocols are established
|Assessment of client
Clients are assessed for suitability for inclusion in model of care based on set criteria
|Development of care plan
Care coordinator works with the client (and carer) to identify and prioritize needs
Care coordinator invites relevant service providers according to stated needs of the client to form a care team
With the principal voice given to the client (and carer), the care team develops a care plan that is client-centered
Care coordinator remains the central point of contact and communications unless decided otherwise by the care team
Although agency-specific records of clients are not shared, there is sharing of minutes of care team meetings
|Identifying participants in care and assigning roles
|Establishing communication pathways to clients and other participants
|Execution of care plan
Needs are addressed according to the priority set by the client (and carer)
The relevant service provider takes responsibility to address needs of the client assigned to him/her
Care team meets regularly with the client (and carer) and care coordinator to discuss progress
After the client believes that the systems to address all his/her needs are in place and working well, the client is free to leave the initiative. Clients can rejoin the initiative if necessary
|Monitoring and adjusting care
|Evaluation of health outcomes
Changes in client needs are monitored every 3 months using the Camberwell Assessment of Needs Short Assessment Schedule