Evaluation of an innovative program to enhance intersectoral collaboration between child protection and mental

health services: Worker and parent perspectives

Fiona Arney, Carole Zufferey, Ruth Lange

Context

• High rate of mental health concerns in the community, deinstitutionalisation

• Impact of parental mental illness on children, and high frequency of child removal

• Layton Report (2003)• South Australian Government - “Keeping

them Safe” child protection reform agenda• National initiatives e.g., Children of Parents

with a Mental Illness (COPMI)• Local initiatives

Research on intersectoral collaboration

• Generally positive attitudes to collaboration• Barriers include:

– communication between different sectors– knowledge and confidence – role conflict and problems with role clarity– resource issues– lack of supportive structures/policies – confidentiality and– statutory requirements

(Darlington, 2005b; Scott, 2005)

Levels of collaboration

– Cooperation

– Collaboration

– Coordination

– Merger/integration

Frost 2005

Background to the Mental Health Liaison Project (MHLP) • Aberfoyle Park Families SA Office in South

Australia• Proposed by workers in response to barriers for

clients accessing mental health services:– waiting lists– strict criteria– clients’ reluctance to follow up mental health

assessment voluntarily – the inability to access services due to

geographical location– client denial of mental health issues– Families SA focus on the child rather than the

parents.

The Mental Health Liaison Project

• Fast track referral for parents with a mental illness

• Situating a mental health nurse within a Families SA District Office

Objectives of the MHLP

• Project objectives:– To improve outcomes for adults and children;– To improve communication across mental health

(MHS) and child protection services (Families SA); and

– To develop collaborative processes and understanding across the service systems working with this client group.

• Although preventive focus compromised by resourcing issues at Families SA – very few new investigations.

Project Referral Data (MHLP)

• Since April 2005-Dec 2005: 18 client referrals from 16 families, more referrals since

• Referrals from Intake and Assessment Team at Aberfoyle Park, Noarlunga and Marion Families SA.

• Child protection concerns were very serious

Mental health issues for clients

• Clients were diagnosed with a range of mental health problems– current diagnosis or previous history of major

depression;– in four families a parent had schizophrenia;– self-harming behaviour or suicidal ideation for four

clients– included mood disorders, personality disorders, post-

traumatic stress disorder, anxiety, phobias and situational crises

Social issues of clients

• substance use

• domestic violence

• a history of childhood abuse

• low intellectual and learning abilities, and literacy problems

MHLP Activities

• Partnership with Flinders Medical Centre/Southern Mental Health

• Reference Committee• Advancing Agency Sharing Forum, August 16th

2005• Consumer/Carer Telephone Conference• Identifying and Developing Mental Health

Resources (including checklists and referral tools) and Mental Health Education

• Joint Assessments and Mental Health Consultation

MHLP Activities (cont.)

• Case Conferences and linkages with Drug and Alcohol Services, and Community Women’s Health

• High Risk Infant Program Subcommittee• External Evaluation• Marion Families SA and DASSA Partnership

Project• Joint Training Initiatives with COPMI (“Families

in Mind”)

Aims of the Evaluation Project

•The key objective of this project was to conduct a process evaluation of the Mental Health Liaison Project (MHLP) at Children, Youth and Family Services, Aberfoyle Park District Centre.

•The evaluation aims to examine the views of workers, supervisors, managers and clients about what worked well, what could be done differently, and what are the facilitators and barriers to collaboration, when including a mental health worker with child protection services.

•Using action research methods the information gained in the first stage of the evaluation was used to inform and enhance practice in the final 3 months of the MHLP.

Research Questions

• What are staff and clients’ perceptions of the MHLP?

• Did the project help to address gaps in mental health and child protection services?

• Did the project lead to perceived increased intersectoral collaboration?

• In this project, what were the facilitators and barriers to intersectoral collaboration between mental health and child protection services?

• What changes could be made to the program to improve intersectoral collaboration and to improve the process for families?

Evaluation – Design

• Action research methodology, process evaluation• Qualitative interviews with staff and clients involved with the MHLP, project data, examination of casenotes•Content Analysis•Interim Report with short, medium and long term recommendations•Changes to the MHLP•Re-evaluation•Final report

Interview Questions

• What has been the extent of your involvement with the project?

• How helpful has it been? What worked well?• For example: Did it improve the way the team

worked? Has it increased your awareness of mental health/child protection or improved agency collaboration? Did the mental health nurse link you with services that you may not have used otherwise?

• What could have been done differently? How?• What else would you like the project to

undertake or assist with?

Constraints

• Timing of evaluation (no pre-data)• Complexity of client issues• Positive response bias?• Staff turnover, mobility of families• Crises prevent participation• Difficulty in contacting client group (although

high response from those contacted – thanks to Lyn Clothier)

• Delays to the start of the MHLP – administrative issues

Respondents

• Staff: five focus groups (four in Families SA and one in MHS) and 11 face-to-face interviews with workers and managers. A total of 25 individual workers, 6 from MHS and 19 from Families SA were involved.

• Parents: two parents had Families SA involvement prior to the MHLP, and six parents had direct involvement with the MHLP

General Perceptions

• In almost 5 years now, it has been the one truly innovative project that I have seen that has worked. This is one of the best projects that I have actually seen in the department in terms of being viable, being accepted, being useful and working at a ground roots level…it has been a wonderful project. (Families SA worker)

• “Mental health is one issue…child is another issue…issues bounce back and clash each other… Families SA need to take mental illness seriously, serious things could happen” (Parent)

• The project profile within Families SA has made it easier for liaison with MHS to happen and certainly made workers in Families SA more aware about MH issues, I have noticed improvement in responses in the last 5-6 months from workers in Aberfoyle Park Office and 4-5 months from Marion Families SA Office due to informal education undertaken by the Project Officer…workers appear to more readily go out and are happy to have joint visits (Mental Health worker)

Findings – Working Well (Workers)

• Unanimous support for the project• Approach of the mental health worker• Education and training• Assessment tools and checklists; • Joint assessments and case conferences; • Reference Committee meetings & clinical

supervision; • Referral processes – access and flexibility; • Links with other collaborative projects

Findings – Working Well (Parents)

• Unanimous support for the project;• Referral; • Handouts, information and practical advice;• Project Officer’s manner and accessibility;• Project supported both parents and

children;• Made the parents feel important/listened to

Quote from parent

• “It is good to have a Mental Health Nurse in Families SA for people like me, to help me ‘keep my mind straight’, so I don’t lose control at the children”. (Parent involved with the MHLP)

Findings – Do Differently, How (Workers)

• Continuation of the project, and permanent

• Expansion across offices and across teams

within offices (“pockets of expertise”);

• Replicated within mental health services;

• More education and training opportunities;

and

• More resources

Findings – Do Differently, How (Parents)

• Continuation of the project, and permanent

• Continuity of service;

• Practical assistance and child care;

• Psychiatrist based at Families SA;

• Comments re Families SA (not MHLP): high staff turnover; Planned appointments; “Under surveillance”, feeling of being judged; Offer ideas or assistance rather than just monitoring; Longer visit; lack of communication about case

Quotes from parents

• “Nothing she could have done differently, good

service and not sure what else she could have

offered” (Parent involved with the MHLP)

• “I should have kept following her up. I’ve been

thinking about her a lot lately. I might ring her

to talk to her. She was good… If I was able to

follow up suggestions, it may have worked

better” (Parent involved with the MHLP)

Facilitators of collaboration (Workers)

• Mental Health Nurse as link between services; • Co-work and joint assessments;• Informal/formal education; • Advocacy for clients and for both service sectors; • Building on previous positive examples; • High profile of MHLP; • Increased information and knowledge sharing; • Shared emphasis on parents and children; • Project Officer’s approach, accessibility and

availability; • MHLP was developed locally and is locally based; • Perception of nursing role as nurturing, therapeutic

Worker

“It is important to be able to continue to have someone involved in that type of position, who can be vigilant in maintaining contact with MHS and Families SA… raising issues from both sides, child issues and MH issues and keeping them prominent, so they are not being overlooked.” (MH worker)

Facilitators to participation (Parents)

- Project facilitates collaboration; - Involvement with/referral to supportive

services; - Accessibility/availability of the MHLP; - Being listened to and offered practical help- Worker’s approach– Understanding and knowledge of family

background/history;- Worker and parent belief and recognition of

ability to care for child, to be a “good parent”; - Acknowledgement of informal supports is

important.

Findings – Barriers to collaboration (Workers)

• Complexity of the issues faced by families

• Staffing and resource issues

• Different service orientations and worker perspectives;

• Gaps in interpretation of legislation;

• Inadequate staff training;

• Resistance to new ways of working; and

• ‘Us and them’ culture

Timing - Staff Turnover

• “We lost lots of staff, lost all our experienced staff, supervisor and senior practitioner-no experienced staff whatsoever, so new intake workers were dealing with crisis after crisis… we didn’t utilise her as well as we could have.” (Families SA worker)

Findings – Barriers to participation (Parents)

• Complexity of the issues faced by families

• Staffing and resource issues

• Parents (MHLP): – Termination of services, – Conflict between mental health & parenting, – Confidentiality issues, – Bad experiences with MHS

• Parents (non-MHLP): – Families SA as a stressor, – Feeling “under surveillance”

Recommendations – Short Term

• Continuation of the MHLP, expansion;• Dissemination activities;• Development of mental health resources

including checklists and tools;• Key liaison persons from MHS and

Families SA;• Continued inter- and intra-agency training

and education sessions; • Formalise practices for other workers• Build on recommendations from previous

report

Recommendations – Medium Term

• Involvement of the Project Officer in policy development for both agencies

• Further build MHLP links and networks

• Document practice philosophy and skills – reflections on practice (noting transferabilities)

Recommendations – Long Term

• Make the project permanent and embed it in

policy and practice;

• Consider early intervention role of mental

health and child protection services (assist

the aims of the MHLP)

• Examine links with NGOs that can offer

support to families with mental health

problems