FINAL REPORT: MENTAL HEALTH COMMISSION OF NSW … › sites › default › ... · 2020-05-18 ·...

FINAL REPORT: NSW MENTAL HEALTH COMMISSION ENVIRONMENTAL SCAN Integration, collaboration and coordination

APRIL 2020

FINAL REPORT: MENTAL HEALTH COMMISSION OF NSW ENVIRONMENTAL SCAN

TABLE OF CONTENTS

1. BACKGROUND .............................................................................................................................................. 1 2. METHODOLOGY AND SCOPE ......................................................................................................................... 1 3. INFORMATION ABOUT THE LANGUAGE USED IN THIS REPORT ..................................................................... 1 4. FINDINGS ...................................................................................................................................................... 2

4.1. Overall Summary ........................................................................................................................................ 2 4.2. Summary of information – co-ordination ................................................................................................... 3 4.3. Summary of information – collaboration ................................................................................................... 7 4.4. Summary of information – Integration ..................................................................................................... 13

5. SUGGESTED NEXT STEPS TO STRENGTHEN INTEGRATION, CO-ORDINATION AND COLLABORATION .......... 20 APPENDIX 1: SUMMARY OF ARTICLES/REPORTS AND SIGNIFICANT POINTS ........................................................ 26 APPENDIX 2: REFERENCES .................................................................................................................................... 62

FINAL REPORT: MENTAL HEALTH COMMISSION OF NSW ENVIRONMENTAL SCAN 1

1. BackgroundThe Mental Health Commission of NSW [the Commission] engaged the services of Jacq Hackett Consulting to undertake a review of the literature (grey and academic) through an environmental scan, that have defined and/or measured integration, co-ordination and collaboration within a health or related field that involved cross government and nongovernment agencies working together.

The impetus for this work is recognition that the systems delivering services to people with lived experience of mental health issues are often fragmented, leading to a lack of continuity of care. In addition, a review of the Commission undertaken in 2018 recommended that that the Commission strengthen its efforts to enhance integration, co-ordination and collaboration across government and the broader system.

2. Methodology and scopeAn environmental scan was undertaken of existing information, literature and evidence about integration, co-ordination and collaboration, namely definitions, guiding frameworks, barriers/challenges to achievement, success factors and assessment measures. This included the use of google scholar and google, utilizing the following general search terms:

Co-ordination And Health

Co-ordination And Mental health

Collaboration And Health

Collaboration And Mental health

Integration And Health

Integration And Mental health

In addition, websites of relevant organisations were used to supplement the literature / information obtained in the above search. A small number of key informants who were deemed to have information and knowledge relevant to the topic were also contacted and provided information and suggested references to supplement the literature / information obtained above.

The environmental scan was not exhaustive; rather it was a rapid review of readily available information gathered within a limited timeframe. Accordingly, this report is not intended to provide a definitive or complete summary of all the potential information; but rather provides a snapshot on current thinking and pragmatic information in relation to the terms co-ordination, collaboration and integration to assist in the operationalization of these terms in the future activities of the Mental Health Commission.

3. Information about the language used in this reportIt is recognised that words and language can have a profound impact on people. The use of inclusive and contemporary language empowers people and allows important issues to be aired with sensitivity while minimising stigma. It is also recognised that words and terms are sometimes contested and are subject to change


for appropriateness in various settings and that the language used to describe lived experience in particular is still evolving.

In considering the language used in this report it is important for the reader to take into account of the following factors related to its purpose and scope:

• The purpose of the report is to summarise findings from an environmental scan of information, literatureand evidence about integration, co-ordination and collaboration. This means that the language used todescribe service users is the language used in the information sources. For this reason, in this report wehave used terms such as patients, consumers and clients.

• The bulk of the relevant information found was not related specifically to the area of mental health,rather it related more broadly to the health system and the social care system. It is in the field of mentalhealth that the language of ‘lived experience’ has become integral; however, this language was not foundto have permeated more broadly in the literature.

• The environmental scan focused on information about system level integration, co-ordination andcollaboration where it involved cross government and nongovernment agencies working together. Thismeans it focused on locating information about the broader system of care and not the specific andlocalized care provided to individuals. Accordingly, the report does not include information about the rolethat carers and families play in supporting the care coordination of individuals with a lived experience ofmental illness, which is acknowledged as significant and critical.

4. Findings This section provides a high-level summary of the findings of the review, including definitions, barriers/enablers and measurements/indicators as they relate to co-ordination, collaboration and integration. Appendix 1 provides more detailed information about the individual sources of information and a brief summary of relevant points drawn from each of reports/ literature etc included in the review.

4.1. Overall Summary The environmental scan revealed the complexity and interrelations of the terms, co-ordination, collaboration and integration. Many authors highlighted that despite the desire to improve the co-ordination of health and human services and programs there are disagreements in defining the commonly used terms, such as collaboration, co-ordination and integration. It has been suggested perhaps the way to conceptualise these terms is to understand that the integration of services/ systems is a continuum where movement from co-operation to co-ordination to collaboration and finally to integration occurs with growing levels of connectedness and decreasing levels of autonomy and independence until they operate as a single system or entity.


(Ref: Adapted from Fine et al, 2000 and Australian Research Alliance for Children and Youth People 2013)

The environmental scan also suggests that integration is currently a primary goal of health systems across jurisdictions, and that it is intended to describe a more comprehensive and complex endeavor than either collaboration or co-ordination. Accordingly, it may be helpful to think of integration as an outcome being sought, and collaboration and co-ordination as processes that may contribute to achieving that outcome. Indeed most discussions of integration or integrated care include the need for collaboration and co-ordination to be part and parcel of the suite of processes involved.

While the following section summarises the information as it relates specifically to each of the three terms [as was required by the project terms of reference], there was significant overlap in the information pertaining to each.

4.2. Summary of information – co- ordination The majority of information and articles identified through the environmental scan related specifically to the field of care-co-ordination, i.e. focusing on how care was provided to individual consumers through efforts such as case management, multidisciplinary teams and co-ordination efforts between individual clinicians involved in the care. As the purpose of the environmental scan was to focus on co-ordination across government and the broader system, information related to care co-ordination was excluded.


Definition of co-ordination

The environmental scan again found there was no single or consistent definition of co-ordination and it was used in reference to both case co-ordination (that is co-ordination at the individual service level) and co-ordination more generally between agencies providing or delivering services.

In some cases, the definitions used the term coordinated in the description, thereby not helping to clarify meaning [e.g. Independent organisations working in a cohesive and coordinated way]

Characteristics embedded in the concept of co-ordination found in the literature included:

• Alignment of effort between organisations

• Placing consumers at the centre of service delivery

• Continuity of contact and communication between providers

• Structured and agreed processes for working together

• Common agenda

Barriers and enablers

In terms of system level co-ordination, the environmental scan identified the following enablers from a small number of sources:

• Clear entry points

• Documented service delivery pathways

• Documentation for staff that defines responsibilities, practices, processes, protocols and systems toenable different program areas and organisations to work together in partnership in the delivery ofservices to consumers

• Participation in local multiagency service co-ordination networks

• Agreements between services, including GPs, for communication and information sharing.

• Robust governance arrangements

• Clearly articulated and documented roles and responsibilities of partner agencies/services

• Specific roles dedicated for co-ordination at the system level to lead engagement across the health andsocial care system (see Brophy for a description of the role of ‘boundary spanner’]

Learnings from collective impact co-ordination initiatives identifies five conditions of collective success as:

• Common agenda

• Shared measurement systems

• Mutually reinforcing activities

• Continuous communication

Co-ordination occurs when services form partnerships to deliver supports to the same client

Ref:

NSW Health Integrated Service Response Operations Manual


• Backbone support organisations

The environmental scan identified the following barriers from a small number of sources:

• Financial and resourcing barriers

• Complications associated with the public/private and primary/specialist care within a fee-for-servicemodel, which limit co-ordination possibilities

• Issues of confidentiality and information sharing between services

• Competing organisational agendas

Measurements and indicators

The manner in which health service or system co-ordination may be measured is somewhat fraught; in part because of the generic nature of what might be considered “co-ordination”, the situation or project specific or context in which the co-ordination is occurring and also because of the various levels co-ordination may occur. This is highlighted by Banfield (2012) who identified that, in respect of mental health, the lack of definition of co-ordination at the policy level reduces opportunities for developing actionable and measurable programs and also impacts on the lack of rigorous evaluation applied to co-ordination of mental health care. This was supported by other authors in the literature review who identified that key challenges remain in reaching a consensus about what constitutes care co-ordination, building the evidence base for care co-ordination, and developing measures of co-ordination.

This has implications for the ability to define the type of indicators that might be developed that allow co-ordination to be assessed, namely that there is no predetermined or tested set of indicators. Notwithstanding these constraints, the literature does suggest that the following approaches may be used to evaluate effectiveness of co-ordination (and could be applicable at the service delivery and the system level):

• Network analysis – which provides a method of examining issues of service fragmentation and co-ordination; it allows the co-ordination of the service system to be measured and quantified.

• Questionnaire / surveys – that allow the measurement of perceived levels of co-ordination

• Audits – which enable co-ordination to be measured by assessing the existence and compliance of co-ordination aspects against a set of criteria or best practice guidelines.

Information regarding criteria on which to measure the quality of service co-ordination at the system level, organisational level and practice level was also described in the literature, including:

Criteria Description

Service co-ordination at a systems level, that is, across organisations

There is evidence to suggest that service co-ordination elements are embedded within organisational operations and practice

Service co-ordination at an organisational level, that is, across multiple programs

There is evidence to suggest that service co-ordination has been integrated and accepted in all relevant program areas within an individual organisation and is embedded into usual practice


within an organisation

Service co-ordination at a practice level

There is evidence that initial contact with consumers has occurred in accordance with service co-ordination practice standards

There is evidence that the initial needs identification process has occurred with service co-ordination practice standards

There is evidence that the assessment process has occurred with service co-ordination practice standards

There is evidence that the care / case planning has occurred with consumers and service providers participating in their care in accordance with service co-ordination practice standards

There is evidence that additional processes including information provision, consent, referral, information exchange, service delivery and exiting have occurred in accordance with service co-ordination practice standards

There is evidence of compliance with privacy and consent requirements


4.3. Summary of information – collaboration

Definition of collaboration

The results of the environmental scan suggest that there is no one universally accepted definition of collaboration within the context of health. A range of definitions are provided that range from simplistic in nature, such as:

“involves multiple people interacting to achieve a common goal”

to more dynamic and complex in nature, namely

“a dynamic, transforming process of creating a powersharing partnership for purposeful attention to needs and problems (practice) to achieve likely successful outcomes’’.

The literature acknowledges that collaboration occurs at all levels of the health system; at the individual client level, at the service delivery level and at the system wide level.

What was apparent from the literature is that collaboration is both a process and an outcome and that there are a number of key inputs and outputs that characterise collaboration as described below:

Inputs

partnership between professionals and/ or institutions

involves two or more entities / parties

it is active, ongoing and durable

It is a synergistic alliance that is mutually beneficial

it involves cooperation, communication, negotiation, trust, respect, and understanding

it involves working together, negotiating agreement and managing conflict

it is underpinned by valuing and understanding one another

involves a synthesis of different perspectives

Outputs

towards or creating a shared purpose / common goal

is problem focused and a provides for a collaborative process to better understand complex problems

shared responsibility for obtaining goals (which facilitates the achievement of goals that cannot be reached when individual persons or organisations act on their own)

based on shared objectives, responsibility, decision making and power

where the contributions of each participant / agency are maximized

Collaboration occurs when multiple services work together in complex ways to change the way the service system operates

Ref:



results in collective action

To summarise these many elements the literature seems to suggest that there are four key elements to collaboration:

1. Co-ordination (working to achieve shared goals)

2. Cooperation (contributing to the team/ project, understanding and valuing the contributions of other team members/ agencies)

3. Shared decision-making (relying on negotiation, communication, openness, trust, and a respectful power balance)

4. Partnerships (open, respectful relationships cultivated over time in which all members work equitably together)

The scan found limited information in relation to the meaning of collaboration within the context of mental health; however, one author did suggest that

“collaborative mental health care is not a fixed model or specific approach; rather, it is a concept that emphasizes the opportunities to strengthen the accessibility and delivery of mental health services “.

It was also acknowledged that successful collaborative mental health initiatives recognise the need for systems and structures to support collaboration, including formal and informal structures that define the ways in which people work together; and organising and creating systems that define what they agree to accomplish together.

It is also worth noting the relationship between “whole-of-government”, which was defined for the Australian Public Service in 2004 as “…public service agencies working across portfolio boundaries to achieve a shared goal and an integrated government response to particular issues” and collaboration. Collaboration provides a vehicle to give effect to the whole of government approach, where agencies work across traditional portfolio boundaries, develop an integrated approach to a complex or cross-cutting issue and share responsibility for an outcome, including the risks and rewards associated with the project.


The literature acknowledged that many failures of collaboration are not because collaboration cannot deliver improved services, but because effective collaborative relationships failed to develop because of the presence of barriers (that could not be overcome) and/ or because of the lack of enablers. The literature included in this review provides information on some of key influences of collaboration within health and these are detailed below and presented as enablers and barriers.

Enablers

Enabler Relevant points from the literature

Organisational structures

Support is required from the organisation’s administration and management to enable and facilitate effective collaboration


Organisations need to share dimensions/ aspects of work that would traditionally be governed by organisational boundaries for collaboration to be effective e.g.: Intellectual Property, contractual risk

Sharing personnel across organisations may also be a key element of successful collaboration

Common / shared goals and responsibilities

It is important for organisations to have a common interests and common goals for the collaboration to be effective

Collaboration is supported and maintained by shared responsibility for management, shared resources,

Work towards a shared vision and outcomes, and adapt as this changes at different stages of the collaboration engagement lifecycle.

Focus on jointly defining and solving critical problems: all parties are prepared to come to the table not knowing what the answers are.

Communication (including honest and open dialogue)

Collaboration benefits from engagement in open and honest dialogue about what organisations want to achieve

Utilise meetings between stakeholders to facilitate collaboration

Communicate early and often

Focus on the development and delivery of a common ‘language’ of processes, practices, frameworks and systems.

commitment of each of the stakeholder

Trust and respect

Strongly related to communication as above, are issues of trust and respect:

• For collaboration to be successful trust should exist or be built between the professionals / organisations involved

• Respecting and having a positive view of the role and the workers of the other agency is a fundamental component of an effective collaborative relationship

Membership characteristics and interpersonal skills

Know yourself and your organisation well as each person in the organization will have a somewhat different mental model of how the collaboration will proceed and being aware of these differences will ensure that processes associated with collaboration are managed

Learn to value and manage diversity to facilitate a collaborative process

Develop constructive conflict resolution skills as conflict can hinder collaboration but managed and resolved well it can facilitate collaboration

Master interpersonal and process skills


Reflection and flexibility are essential to ensure that the tasks being focused on are actually the shared priorities of the group.

Roles and responsibilities

Work with clear roles and expectations across complex thinking and delivery challenges.

Share capabilities and leverage each party’s strengths and support areas of weakness.

Take accountability for success and failure and ensure that those with accountability are adequately set up to succeed.

Resources The adequacy and allocation of resources have also been identified by many authors as important factors that facilitate an effective collaboration

Barriers

Barrier Relevant points from the literature

Structures and policies

Absence of effective interagency structures, processes and policies, including effective liaison processes and guidelines, have been highlighted as a barrier to collaboration. Without structures and policies that support and encourage interagency collaboration, individual workers find it difficult to initiate and maintain cross-organizational relationships

Structural barriers to collaboration include differences in the regulatory, financial, and administrative boundaries.

Lack of support from the agencies’ leadership and management

Territorialism and a lack of a systems view can undermine collaborative efforts

Staff and organizational changes

Resources

There are three items related to resource allocation: a lack of time, high workloads, and lack of appropriate funding / capacity

Inadequate resources also leave workers without time to establish and maintain contact with other agencies and create ‘gatekeeping disputes’

Cultural Cultural impediments consist of the variations in the manner in which organisations and individuals work which may negatively impact on the success of a collaborative endeavour.

Communication Lack of knowledge

Poor information flow


Lack of trust and respect

Professional knowledge domains and boundaries.

Professionals from different disciplines and/or working in different agencies may operate with different knowledge bases, discourses, and conceptual frameworks, differing theoretical bases, feelings of ownership of clients, conflicting aims and expectations, and differing perceptions

Philosophical differences

Unrealistic / Different expectations

Lack of clear boundaries and agreed goals for the process.

The literature also notes that collaboration is as much about shifting culture and mindset as it is about skills, processes and practices. For collaboration to be successful and effective, all parties need to be prepared to change their operating model and follow through on that change to deliver services / programs in a collaborative way. The preparedness to give up organisational autonomy, power and established ways of operating to deliver in a new way is a key to the success of a collaborative endeavour.


The literature includes some information on the effectiveness and success of collaborative endeavours both at a service level and a system level in health. However, there is a challenge for the development of indicators and therefore how the effectiveness of collaboration would be measured. In the main this is due to the notion that collaboration is project/ initiative specific, collaborations are often dynamic in nature, it is difficult to define or measure outcomes and the length of time required for interventions to effect outcomes are considerable.

Notwithstanding this, a number of instruments/ approaches have been used by agencies and individuals to measure the success of a collaboration, these include:

• Instruments / survey designed to quantitatively score collaboration (or rather perceptions of collaborative behaviour). Such measures recognise the difficult in assessing collaboration objectively through observation (which would be difficult to accurately quantify).

• Network analysis which involves mapping formal and informal links between collaborators.

• Semi structured interviews of staff who undertake a global rating of interagency collaboration in addition to a thematic analysis of the content of the interviews.

The following instruments that have been developed may have relevant application to this project:

The Collaboration Health Assessment Tool (CHAT)

The Collaboration Health Assessment Tool (CHAT) (Noone et al 2017) is described as an online resource for measuring how collaborators are working together now and into the future.

CHAT gives users the option of either interacting with the tool on a “one off” basis or by setting up an account with (or without) their collaborators. Both options will


generate a series of component scores and an overall “health score” for the collaboration.

If desired, CHAT can also be set up to produce scores for each group working in the collaboration (e.g. Backbone, working group, community group).

CHAT assesses the following domains

Structure

Goals

Resources

Authority

Accountability

Process

Whole of system engagement

Communication flows

Adaptive capacity

Authorising environment

CHAT provides:

• A score for each of the eight dimensions of collaboration and an overall score. Scores are based on a traffic light system and can be produced for the whole collaboration as well as for individual groups working within it

• Feedback tailored to the CHAT score. CHAT will generate broad guidelines on how specific elements of the collaboration could be enhanced.

• A printable report. A collaboration’s results and feedback can be printed as a report for easy dissemination to your stakeholders.

• The capacity to track progress over time.

Interagency Collaboration Activities Scale

A scale developed by Dedrick and Greenbaum (2011), the Interagency Collaboration Activities Scale provides is a self-report questionnaire to measure the extent to which individuals perceive their agencies are collaborating with other agencies; it includes the following domains:

Financial and Physical resources

Funding

Purchasing of services

Facility space

Record keeping and management information systems data

Developing programs or services

Program evaluation


Program development and evaluation

Staff training

Public information

Collaborative Policy Activities

Conferencing

Informal agreements

Written agreements

Contractual arrangements

Collaboration Assessment Tool

A collaborative assessment tool developed by Marek et al (2014) which consists of 69 items in relation to the following seven factors

• Context

• Membership

• Process / Organisation

• Communication

• Function

• Resources

• Leadership

4.4. Summary of information – Integration

Definition of integration and integrated care

A key challenge in confirming a definition of integration through the environmental scan was the plethora of different definitions outlined in literature and grey literature. There is clearly no single, universally accepted definition and definitions vary according to the different views of patient, providers, managers and policy makers. However, there are common elements that can be drawn out of the various definitions and descriptions.

The environmental scan suggests a number of characteristics are commonly used to describe integration, as outlined below.

Integration involves:

• Connecting key components of the health care system, namely acute, community-based and primary care services.

• Connecting the health care system with the social care service system [e.g. education and housing].

• Developing systems for sharing information and problem identification

• Coordinating care around the needs of individuals.

• Respecting professional expertise across disciplines and agencies

Integration is achieved when links between services draw them into a single system

Ref:



• Patient centred care, across the life course, enabling access to care when and where it is needed.

• A population health approach.

• Different services and sectors that are usually autonomous and fragmented working together to deliver health and social care for a population or community (often with a multi disciplinary collaboration).

• Bringing community assets together to promote health and wellbeing to populations.

The common aims of integration are to:

• Deliver seamless care across health and social care.

• Reduce fragmentation of care.

• Improve the experience of care for service users, making it easier to use, navigate and access.

• Improve the health of populations

• Achieve a more efficient and cost-effective health care system

Efforts to better understand and more fully describe integration commonly break integration down to a number of different levels. While the specific terminology for these ‘levels’ varies across the literature, and the number of levels varies between 5 and 7, there is common ground. The table below summarises the relevant information across five different levels of integration.

Level of integration Primary focus Common elements

Clinical/practitioner integration

Health and social care services are coordinated and organised around the needs of service users

Multidisciplinary assessment and care planning

Care coordinators

Defined pathways of care

Case management

Single point of entry for multiple services

Administrative/functional integration

Alignment of ‘back-office’ type functions to enable effective communication of data and information across the system of care

Shared data systems

Electronic patient records

Uniform patient identifiers

Funding models

Organisational integration

mechanisms which facilitate providers delivering ‘joined up’ care across the system of care

Shared:

• strategic objectives policies and procedures

• performance and outcome measures

Contractual and funding/commissioning arrangements that support integrated care

Governance mechanisms across the system of care

Effective inter-agency relationships


Systemic/strategic integration

The development of a system wide enabling platform for integrated care

Financing mechanisms

Regulatory frameworks

Supportive national and state policies

Workforce engagement

Normative integration

The development of a shared common frame of reference in relation to integrated care across organisations, professional groups and individuals

The achievement of common vision and values related to integration

Shared goals for integration

A culture of trust and commitment


The environmental scan suggests that achieving integration is complex and requires change and effort at multiple levels. Common barriers and enablers identified across the information reviewed are outlined below.

ENABLERS - RELEVANT POINTS FROM THE ENVIRONMENTAL SCAN

BARRIERS - RELEVANT POINTS FROM THE ENVIRONMENTAL SCAN

Engagement

Empowering and engaging individuals and communities to be influential partners in their own care

Tensions associated with poorly defined roles and responsibilities / inadequate mechanisms for resolving issues

Co-design of stakeholders in service design

Providing the opportunity, skills and resources that people need to be articulate and empowered users of health services and advocates for reform

Flawed assumptions or unrealistic expectations

Ensure all agencies that need to be part of the solution are engaged

Facilitate a cross-agency collaboration approach to issues resolution including clarifying the responsibilities of relevant agencies and removing duplicate processes

Inform, influence and reinforce service roles and responsibilities


Leadership

Strong clinical and executive leadership and management

Conflicting aspirations of different parts of the system

Leaders that enable stakeholders to move beyond past history and experience, and step outside the silos and away from the protection of familiar turf, organizations, professions or jurisdictions.

Leaders not being accountable for the outcomes of their wider system, beyond the accountabilities of their individual organisations.

Leaders modelling the mindsets and behaviours that support the successful integration of care

Empowering local teams to be leaders on the ground

Leaders with vision who are able to instill a strong, cohesive culture

Senior leadership is essential for creating a shared vision and setting out the principles and framework for integration.

Requires shared leadership and language

Ensure agencies leads and confirm when lead responsibility needs to be designated to support resolution

Leverage existing agency relationships

Governance

Governance supports effective decision making and clear accountabilities when integrating care.

Integration requires integrated decision making which is extremely complex due to:

• multiple partners

• organizational, jurisdictional and public and private provider boundaries

• unique cultures

• finite resources

• multiple bodies of professional knowledge and practices as well as business processes.

Effective governance structures are required to support partnerships within and between health care organisations and their interface with social care organisations

Integrated care requires a participatory approach to policy formulation, decision-making and performance evaluation at all levels of the health system, from policy-making to the clinical intervention level.


Bringing together organizations and services into an integrated health system through contractual relationships or networks typically requires development of governance structures that promote co-ordination

Governance provides the framework and leadership for momentum and support to accomplish the integration of services, including for decision making across organisational and jurisdictional boundaries.

Use the governance arrangements to raise issues such as local and system wide barriers to integration

Partnerships

Effective working partnerships and relationships across the health system and its interface with social care are needed to promote clear roles, accountability, trust, shared decision-making and information sharing between partners

Limited interdepartmental collaboration.

perception that secondary care has received a disproportionate share.

Requires a physician–management partnership that links the clinical skills of health care professionals and the organisational skills of executives

Poor relationships between primary and secondary care are widespread. Mistrust and antagonism are often built upon historical battles over resources, with a common

Requires strategic relationship building to drive both process and outcomes

Unless relationships are addressed, the integration process will be dominated by disputes over money and fights to rebalance past injustices.

Culture

Integrating care requires a shift in thinking to create a health service culture that is centred on the needs of the person, is proactive rather than reactive, operates as one integrated system, and increases multidisciplinary and multi-system care

Staff are conditioned by the organisations in which they work.

Cultural transformation is important There are cultural divisions between primary and secondary care and between health and social care

Requires the organizational culture to be congruent with the vision for integration

Services with a major role to play in determining health outcomes (healthcare, social care and education) are administered by different government departments with disparate funding, goals and responsibilities


Requires a collaborative culture that emphasises team working and the delivery of patient centred care.

Funding

Alternative funding models are required to support integrated care, for examples models of block funding for health, education, social and other services

Health, education, social, leisure, faith and correctional services are funded as separate entities by autonomous agencies.

Funding mechanisms influence system wide implementation of integration of care initiatives. Incentives can influence the behaviour of system participants including service providers and clinicians

Fee-for-service funding arrangements, which reward the quantity of services rather than the quality. Such arrangements overlook population health needs and discourage collaboration to address service user needs and outcomes

Requires outcomes-based commissioning arrangements that places the emphasis on achieving the desired outcomes for the service user (rather than the more usual measure of performance by activity)

Insecure ongoing funding of any partner

Requires alignment of financial incentives that avoid the perverse effects of fee-for-service reimbursement and encourages the prudent use of resources and promotes quality improvement

Access a small amount of brokerage funding to build local capability, in exceptional cases.

Technology

Technology provides important architecture to support many of the activities critical to integrating care such as information sharing

Efficient information systems are required that enhance communication and information flow across the continuum of care and enable collection, tracking and reporting of activities

IT systems must support the delivery of integrated care, especially via the electronic medical record and the use of clinical decision support systems

Information


Information plays an important role in ensuring the seamless provision of care is provided in the most effective manner

Most current performance standards are measures of individual organisations within the system, and there are few measures that cross organisational boundaries and follow the whole patient pathway across health and social care. System-wide performance measurement is an area that requires new methodologies for data capture and reporting

Accurate and effective information analytics ensures integrated care is targeted to the people who will benefit most and supports the continuous improvement of the system

Inability or lack of information sharing due to poor or non existence systems

Integrated care requires the ability to share information safely and securely amongst care professionals

Facilitate sharing and agreement of information between relevant stakeholders


The environmental scan highlighted the difficulties in measuring the effectiveness of integration, the extent to which it has been achieved in particular programs, and where achievements were identified, what specific strategies contributed the most. This was primarily due to studies of different models, with different strategies/components but also due to the notion that there are a numerous and varied definitions of what constitutes integration.

Accordingly, it is challenging to determine how the effectiveness of integration should be measured and therefore what the most appropriate indicators are to define what might be considered successful integration.

At an individual service level, the effectiveness of integration has been measured in the following ways:

• Assessing separate components of integrated care e.g. case management, patient experience

• Quantifying the extent, scope and depth of the integration as perceived by local service providers; with extent of integration including the identification and number of services, scope of integration including the number of services that have awareness or links to others; and depth of integration measured along a continuum of involvement.

The methods by which information and data is collected in relation to the measurement of integrated care is varied and includes questionnaire survey data, automated register data and mixed data sources, with the most commonly used method being that of survey questionnaires.

At a system wide level, one study (Durban 2006) in the literature noted that the development of indicators in relation to the following may be useful in evaluating the effectiveness of system level integration:

• System organization—the management structure, the service sectors to be integrated and the resources provided

• System performance—the extent to which a full continuum of services and supports is available, the extent and nature of inter-agency linkages, and the strategies in place to bring services together


• Service outcomes—the continuity of care experienced by clients

• Clinical and quality of life outcomes—improvement in client symptoms, function and quality of life

• Community context—e.g., mental health law, social and health expenditures, vacancy rates.

There were commonly suggestions that more sophisticated work needs to be done to expand the evidence base with regard to integration and the manner in which integration and integrated care and services are measured.

5. Suggested next steps to strengthen integration, co- ordination and collaboration

In search of a definition

The NSW Health Review of Mental Health Commission - Report to Parliament in 2018 recommended that the Commission refocus its work on the outcomes and impact of cross-sectoral government strategies on improving mental health and wellbeing. This refocusing recognises that

“the achievement of mental health and wellbeing for individuals and society requires not only effective health services, but the contribution and performance of other sectors which have significant mental health impacts”.

In addition, the report indicated that the most common response from organisations about the highest priority for the Commission was “whole of government collaborative approaches”.

This environmental scan represents an initial step in the Commission’s work to clarify its approach in this important area, and to consider how best to optimise opportunities. The review report recognises the important role of the Commission as “a facilitator and collaborator, with a whole-of-system perspective and able to work with supporting agencies”.

In considering how best to implement this role of facilitator and collaborator to strengthen co-ordination, collaboration and integration across the mental health and government system, it will be helpful for the Commission to recognise that the definitions and dimensions of these three terms are very closely inter-related and their meaning is most likely dependent upon the end users frame of reference; accordingly, to focus on the terminology is likely a distraction that may hinder progress. Instead the Commission could ensure that their mission statement provides a clear statement about its role in enhancing system integration, acknowledging that it will use many strategies to enact this vision, potentially aligned with the NSW Government definitions highlighted elsewhere in this report and repeated below:

• Co-ordination occurs when services form partnerships to deliver supports to the same client.

• Collaboration occurs when multiple services work together in complex ways to change the way the service system operates.

• Integration is achieved when links between services draw them into a single system.

Ref: NSW Health Integrated Service Response Operations Manual

Contributing to system enablers

The environmental scan identified common enablers to achieving effective co-ordination, collaboration and integration, which are helpful in directing the Commission’s role in facilitating cross-agency efforts. The system


enablers identified through the environmental scan align well with the system enablers identified NSW Strategic Framework and Workforce Plan for Mental Health 2018-2022 which states these are

“the critical factors that will help NSW Health achieve the vision for mental health across the next five years”.

The table below outlines the eight system enablers identified NSW Strategic Framework and Workforce Plan for Mental Health and maps key findings from the environmental scan that align with each of these.

Note: while enablers were identified for each of the three terms (coordination, collaboration and integration), the most robust information found was for integration. As this report suggests in section 4.1, integration is currently the primary goal of health systems broadly, and NSW Health specifically. In addition, the continuum identified on page x suggests that coordination and collaboration are required to achieve the ultimate goal of integration. Accordingly, the table below focuses on aligning the eight enablers from NSW Strategic Framework and Workforce Plan for Mental Health with relevant information from the environmental scan related to the achievement of integration.

Enablers identified in the NSW Strategic Framework and Workforce Plan for Mental Health

Relevant findings from the environmental scan

1. Culture Enablers to achieving integrated care include:

• Cultural transformation strategies

• Organisational culture that is congruent with the vision for integration

• A shift in thinking at the system level to patient-centred care

• A system that operates as one integrated system.

2. Leadership and governance

Enablers to achieving integrated care include:

• Strong leadership to:

o Drive integration

o Develop the necessary organisational culture required to support change.

o Facilitate shared goals and a common agenda for integration at senior levels (across and within agencies).

• Shared governance structures are required to support integration, including:

o Clarity about roles, responsibilities and accountabilities.

o A participatory approach to policy formulation, decision-making and performance evaluation at all levels of the health system, from policy-making to the clinical intervention level.


o Support partnerships within and between health care organisations and their interface with social care organisations

3. Guidance


• A participatory approach to policy formulation.

• Clearly defined and documented responsibilities, practices, processes, protocols and systems to enable staff from different program areas and organisations to work together in partnership in the delivery of services to consumers

4. Funding and performance


• High-level discussions related to funding and performance.

• Identifying alternative funding and commissioning models to support integration

• Support for designated funding for co-ordination and infrastructure requirements.

• Shared accountability and performance measures to assess system wide effectiveness of integration efforts.

5. Service delivery and partnerships


• Strong partnerships across the interface of mental health, health and social care services.

• Strategic relationship building to drive system level change.

• Co-design processes to underpin efforts to enhance integration, bringing together consumers, families and support people with health service leaders, policy makers and service delivery staff.

6. Technology and systems


• Technology that enables communication and information sharing across the system of care.

• IT systems that support the delivery of integrated care, including via electronic medical records and the use of clinical decision support systems

• Technology that enables collection, tracking and reporting of activities

7. Information & planning


• The ability to share information safely and securely amongst care professionals


• Accurate and effective information analytics to ensures integrated care is targeted to the people who will benefit most and supports the continuous improvement of the system

• Agreements between services for communication and information sharing.

8. Workforce


• A workforce focused on the delivery of patient-centred care.

• Clinical and management leaders as well as partnerships between the two.

• Specific roles dedicated for co-ordination at the system level to lead engagement across the health and social care system

Evaluation and indicators

The environmental scan highlighted the importance of evaluating efforts to enhance co-ordination, collaboration and integration, and it also highlighted the difficulties in applying a one size fits all in doing so. As such, it is suggested that any evaluation undertaken by the Mental Health Commission will be required to be fit for purpose. Given the notion of a continuum presented elsewhere in this report, it is suggested that such an evaluation should include the following:

Process evaluation that assesses the process of implementing strategies and activities that facilitate co-ordination and collaboration.

Impact / outcome evaluation that assesses the longer-term impact of the implementation of such strategies on service and system integration.

It is worth noting that such an approach is supported by the NSW Government which identifies the need for Government agencies to undertake appropriate evaluations that include process and outcome measures1.

Commission’s draft Indicators Report

A key task outlined in the project brief for the environmental scan was to: Consider the Mental Health Commission of NSW draft Indicators Report to determine intersections and opportunities for measuring integration, collaboration and coordination.

In 2018 the Commission undertook a review of its existing headline indicators, in order to develop a revised indicator set to effectively monitor current objectives and activities in NSW Mental Health Reform. The report was

1 https://www.dpc.nsw.gov.au/tools-and-resources/evaluation-toolkit/evaluation-in-the-nsw-government/

https://www.dpc.nsw.gov.au/tools-and-resources/evaluation-toolkit/evaluation-in-the-nsw-government/


scanned to identify areas of particular relevance for measuring impact in the key areas of focus for this environmental scan.

Within the report, indicators are defined as the key markers of change for each of eight outcome domains; headline indicators are defined as the priority or most important indicators; secondary indicators refers to indicators that were not assessed as being a priority. For each indicator, a set of measures was identified, based on a review of a range of existing data sources and assessed against a range of criteria including relevance, reliability, validity and ability to measure progress over time. Where there were data gaps, the report proposed that measures be developed via a survey of NSW individuals and/or service providers.

Of the twenty-one headline indicators identified in the report, two were assessed as having particular relevance to this environmental scan as follows:

• Headline indicator 6: Service delivery integrated to meet a person’s needs

• Headline indicator 11: Transformed system

Information in relation to measures and data sources for these two headline indicators are outlined in the table below.

In considering intersections and opportunities for measuring integration, collaboration and coordination the following is noted:

• While headline indicator 6 has five measures, it is measures 4 and 5 that are considered the most relevant for the purposes of measuring system integration [as opposed to coordination of care for individuals]

• For those two measures [4 and 5] no existing data source is identified, rather it is proposed that data is collected via a survey of NSW health service provider.

• In relation to headline indicator 11, there is neither a measure or a data source provided, rather it is suggested that these are co-designed with key stakeholders.

Headline indicator 6: Service delivery integrated to meet a person’s needs - working together to design, plan, fund and improve co-ordinated and integrated services

Measures Source

1. Percentage of people with a mental health condition who reported that a health professional did not help coordinate care

ABS Patient Experiences Survey

2. Number and percentage of referrals made by an agency to other support services agencies

Indicator proposed for development -possible sources include administrative data systems of service providers or survey

3. Percentage of people experiencing mental health issues who reported that they were able to obtain referral/information about other support services through service providers that they had visited for services

Indicator proposed for development through survey of individuals

4. Number of service providers that are part of a formal partnership with other service providers

Indicator proposed for development through survey of service providers


and are aware of the services that are provided by services in their partnership

5. Number of service providers that regularly collaborate with other service providers and are aware of the services that are provided by services in their partnership

Indicator proposed for development through survey of service providers

Headline indicator 11: Transformed system: The extent to which key enablers and elements of reform is taking place

Measures Source

To be co-designed with key stakeholders (to include measures of enablers such as interagency collaboration, governance etc)

TBC

Note: of the 61 secondary indicators, only one is considered to have direct relevance to the environmental scan, namely, number 26, data capabilities between health and human services.

Next Steps:

To progress strengthening the Commission’s efforts in relation to integration, co-ordination and collaboration across government and the broader system it is suggested that the Mental Health Commission establish

governance and consultation mechanisms that bring together its key stakeholders to:

• Discuss determine how best to position the goal of integration in line with the purpose and mission of the Commission.

• Plan for the development of activities / initiatives that lead to co-ordination and collaboration.

• Plan for activities that facilitate system integration by enhancing known enablers and address barriers.

• Develop appropriate evaluation methodologies that incorporate process and outcome measures.

The review of information in the draft Indicators Report suggests the next steps in relation to evaluation and indicators are to:

• Develop the survey of service providers as indicated for headline indicator 6; and

• Initiate a co-design process to develop measures and potential data sources for headline indicator 11.


APPENDIX 1: SUMMARY OF ARTICLES/REPORTS AND SIGNIFICANT POINTS

Reference Brief Summary / Significant points

Co-ordination

1. Definitions

Keast 2013

Fact sheet that describes the 3 Cs – cooperation, coordination and collaboration as components of a relationship continuum. Suggests that each of the Cs has distinct characteristics and purposes, with coordination defined as follows:

Coordination is based on a greater sense of interdependence between organisations. In coordinated approaches, the parties realise the need to work together to meet a set goal. This process requires participants to tightly align resources and effort. Although involved in set joint policies and programs, organisations retain control over their own operations. Coordination requires a higher level of contribution and commitment as well as stronger relationships between participants. These stronger relationships are often based on prior relationships and experiences between participants.

The 3Cs relationship continuum with key characteristics is outlined below.

Primary Care Partnerships Victoria

Service coordination places consumers at the centre of service delivery to maximise their opportunities for accessing the services they need.

Service coordination enables organisations to remain independent of each other, while working in a cohesive and coordinated way to give consumers a seamless and integrated response. Service coordination is underpinned by the principles shown.

The aim of service coordination is to ensure consumers receive a seamless and integrated service response. This does not mean that one service provider must provide



Co-ordination

all services. However, it is each service provider’s responsibility to provide access and coordinated care to meet the consumer’s full range of needs in a timely manner.

Outlines a framework that comprises four core components:

• Initial contact • Initial needs identification • Assessment • Care/case planning

Plus the following additional processes:

• Information provision • Consent to share consumer information • Referral • Information exchange • Service delivery • Exiting

Banfield

Finds that policy and strategy documents regarding coordination of care worldwide do not provide clear definitions for terms such as coordination, integration, continuity and access to care, nor in relation to where and how they should be occurring.

Provides a definition from Hagerty et al ‘coordination in mental health involves continuity of contact between a team of providers and the consumer that facilitates the flexible delivery of services to meet individual needs’.

El Ansari, 2011 This paper highlights the need to standardise terminologies to assist in the delivery of integrated care. In relation to collaboration versus integration they highlight that:



Co-ordination

some authors contend that collaboration is simply the act of working together, whereas coordination involves regulation of participants to produce higher-order functioning

Kania 2011

Article focusing on collective impact – which they describe as an innovative approach to coordination aimed at addressing social issues in areas like health and education in a systemic way. Collective impact requires many different players to change their behaviour in order to solve a complex problem. States that collective impact initiatives involve a centralized infrastructure, a dedicated staff, and a structured process that leads to a common agenda, shared measurement, continuous communication, and mutually reinforcing activities among all participants.

Suggests that large-scale social change comes from better cross-sector coordination rather than from the isolated intervention of individual organizations. They state that evidence of the effectiveness of this approach is still limited, but examples suggest that substantially greater progress could be made in alleviating many of our most serious and complex social problems if nonprofits, governments, businesses, and the public were brought together around a common agenda to create collective impact.

2. Barriers and Enablers


The Victorian Service Coordination Practice Manual 2012 outlines the follow systems and processes that support coordination to enable consumers to access to the service system and the range of services required:

• clear entry points • accurate and reliable service information • access to and an understanding of the initial needs identification, assessment,

care/case planning and referral processes • information about a consumer’s rights and responsibilities • practice that is sensitive to cultural, communication and/or cognitive

requirements • documented service delivery pathways that include early identification for

consumers with complex and multiple issues • clearly defined processes for monitoring, review and recall • up-to-date evidence and resources for staff, including service directories, e.g.

Human Service Directory • competent staff with access to relevant ongoing training, for example in goal

setting, case conferencing, initial needs identification, communication, care/case planning, referral and an understanding of consent and privacy requirements

• documentation for staff that defines responsibilities, practices, processes, protocols and systems to enable different program areas and organisations to work together in partnership in the delivery of services to consumers

• documented protocols to guide a person-centred approach, including multi-disciplinary and interdisciplinary practices

• participation in local multiagency service coordination networks



Co-ordination

• agreements between services, including general practitioners (GPs), for communication and information sharing.

Brophy

Article focusing on care coordination in mental health, specifically in relation to the Partners In Recovery (PIR) initiative. While the bulk of the article focuses on care coordination for individuals (and therefore outside scope of this environmental scan) – the issue of system coordination is also covered to some extent. Key points are outlined below.

Governance arrangements between the different partners engaged in the PIR initiative need to be robust and clearly articulate the role and function of the support facilitation organisation (which may differ from the fund holder organisation), and its relationships with partner organisations. Ideally, formal partnerships and agreements should be in place to clearly identify the expected roles and responsibilities of the different local partner organisations. States it is essential to form these across the broad spectrum of agencies engaged with people with and persistent mental illness and complex needs to ensure that the problems associated with siloed services are not replicated within the PIR initiative.

The need for the role of a ‘boundary spanner’. As the support facilitator is expected to be highly engaged at the client level, their capacity to be engaged in broader health and welfare system change needs support. Given this is a critical area of work requiring a significant level of resourcing, it raises the question as to the need for an additional service integration and coordination role or function.

A term that has been adopted internationally is that of ‘boundary spanner’. This role or function has been described by Williams P as:

network manager. . .building effective personal relationships with a wide range of other actors; the ability to manage in non-hierarchical decision environments through negotiation and brokering; and performing the role of ‘policy entrepreneur’ to connect problems to solutions, and mobilise resources and effort in the search for successful outcomes.

Critical to the success of the PIR initiative is the overarching system change required to facilitate a more joined-up and collaborative way of working. Different PIR initiatives need to incorporate ‘boundary spanning’ into their service model. This needs to complement the activities of the support facilitator.

Notes that the expectation that collaboration can occur without a supporting infrastructure and coordination-dedicated roles is cited by Kania and Kramer as the most frequent reason why large coordination projects fail.

Banfield 2012

Summarises barriers identified from three commonwealth initiatives with a focus on coordination:

• Coordination in mental health is possible, but it requires a complex mix of local planning within broader structural, cultural and policy change, and current



Co-ordination

complications of public/private and primary/specialist care within a fee-for-service model limit coordination possibilities

• Problems identified by jurisdictions included the need to provide additional funding or incentives to set up the pilot sites and implement the coordination models, difficulties progressing the initiative within existing resources, and problems of duplication of services where the different responsibilities of the Commonwealth and State funded programs were unclear

• Service coordination was dependent on solid business and clinical governance to resolve tensions between providers. In particular, issues of confidentiality and information sharing were significant barriers to effective referral pathways between services and competing organisational agendas affected coordination

Kania 2011

Outlines five conditions of collective success for collective impact collaboration initiatives:

• Common Agenda - Collective impact requires all participants to have a shared vision for change, one that includes a common understanding of the problem and a joint approach to solving it through agreed upon actions.

• Shared Measurement Systems - Developing a shared measurement system is essential to collective impact. Collecting data and measuring results consistently on a short list of indicators at the community level and across all participating organizations not only ensures that all efforts remain aligned, it also enables the participants to hold each other accountable and learn from each other’s successes and failures

• Mutually Reinforcing Activities - Collective impact initiatives depend on a diverse group of stakeholders working together, not by requiring that all participants do the same thing, but by encouraging each participant to undertake the specific set of activities at which it excels in a way that supports and is coordinated with the actions of others. The power of collective action comes from the coordination of the differentiated activities through a mutually reinforcing plan of action. Each stakeholder’s efforts must fit into an overarching plan if their combined efforts are to succeed. The multiple causes of social problems, and the components of their solutions, are interdependent. They cannot be addressed by uncoordinated actions among isolated organizations.

• Continuous Communication - Developing trust among nonprofits, corporations, and government agencies is a monumental challenge. Participants need several years of regular meetings to build up enough experience with each other to recognize and appreciate the common motivation behind their different efforts. They need time to see that their own interests will be treated fairly, and that decisions will be made on the basis of objective evidence and the best possible solution to the problem, not to favor the priorities of one organization over another

• Backbone Support Organizations - Creating and managing collective impact requires a separate organization and staff with a very specific set of skills to serve as the backbone for the entire initiative. Coordination takes time, and none of the participating organizations has any to spare. The expectation that collaboration can occur without a supporting infrastructure is one of the most



Co-ordination

frequent reasons why it fails. The backbone organization requires a dedicated staff separate from the participating organizations who can plan, manage, and support the initiative through ongoing facilitation, technology and communications support, data collection and reporting, and handling the myriad logistical and administrative details needed for the initiative to function smoothly.

3. Measurement and indicators

Heflinger 1996

Proposes that Network analysis offers a method for examining issues of service system fragmentation and coordination. The predominant approach taken by network analysts identifies the structural and process dimensions and situational factors connected with the formation and maintenance of relationships, in this case among the agencies in a service system. This method affords the opportunity for measuring and quantifying aspects of service system coordination that are critical to managed systems of care.

Article presents the findings from a Network Analysis undertaken to assess the extent to which a coordinated system of care existed for military dependents at a demonstration site that implemented a case-managed continuum of care and at two comparison sites.

Two measurement instruments were adapted for use:

• The “Fort Bragg Children and Youth Services Network Study (FBNS)” is a self-administered questionnaire measuring the linkages between the respondent’s agency and each of the provider and agencies in the mental health network. The FBNS questionnaire included items designed to assess: (a) awareness of community agencies, (b) frequency of interagency staff interaction, (c) frequency of referrals among community agencies and providers, (d) extent to which formal agreements existed between agencies, (e) amount of client-centered information exchange, (f) extent of activity coordination among community agencies, (g) mutual goal attainment, and (h) satisfaction with their relationships with each of the other agencies and providers in their area.

• The “Assessing Local Service Systems for Military Dependent Children and Youth (ALSS)” instrument was designed to assess service system effectiveness specifically for the target population, including capacity and performance, and covers several domains including: (a) the range of problems experienced by military children and youth in the area; (b) the availability, adequacy, and quality of mental health and related services; (c) service system performance, or the extent to which the service system was coordinated and responsive to the needs of this population; (d) service system goal attainment, or the extent to which overall goals of the child mental health service system were being achieved.


The Service Coordination Continuous Improvement Framework outlines 8 criteria to promote a consistent standard of service coordination practice, and enable service providers implementing service coordination to assess and continually improve their performance. By measuring performance against the criteria, service providers can judge the quality of their service coordination implementation at three levels: systems level, organisational level and practice level. This can occur through service provider self-audits, audits of a sample of files by an independent person, cross‑referencing and



Co-ordination

links with organisational quality assurance systems, and discussion and review at team meetings.

Thein relation to the eight criteria:

• Criterion one relates to implementation of service coordination at a systems level, that is, across organisations

• Criterion two relates to service coordination at an organisational level, that is, across multiple programs within an organisation

• Criteria three to eight relate to service coordination at a practice level.

The table below outlines each criterion and an associated list of evidence to show to what extent the criterion has been met.

In applying the Continuous Improvement Framework, organisations should ask the questions:

• How can our agency demonstrate that this occurred? • What evidence is there to support this? • How can we improve in this area? • What action can we take to improve?

Banfield 2012 Identifies a lack of rigorous evaluation applied to coordination of mental health care.



Co-ordination

The lack of definition of coordination at the policy level reduces opportunities for developing actionable and measurable programs.

Schultz et al, 2013

The authors note that robust measures of coordination processes are essential tools to evaluate, guide and support efforts to understand and improve coordination, yet little agreement exists about how to best measure care coordination. Key challenges remain in reaching a consensus about what constitutes care coordination, building the evidence base for care coordination, and developing measures of coordination.

A systematic review was conducted of measures and among the 96 included measure instruments:

• Most relied on survey methods (88%) and measured aspects of communication (93%), in particular the transfer of information (81%).

• Few measured changing coordination needs (11%). • Nearly half (49%) of instruments mapped to the patient/family perspective; 29%

to the system representative and 27% to the health care professionals perspective.

• Few instruments were applicable to settings other than primary care (58%), inpatient facilities (25%), and outpatient specialty care (22%).

The authors concluded that new measures are needed that evaluate:

• changing coordination needs, • coordination as perceived by health care professionals, • coordination in the home health setting, and • for patients at the end of life.


Collaboration

1. Definitions

Gagne 2005

Collaborative mental health care is not a fixed model or specific approach; rather, it is a concept that emphasizes the opportunities to strengthen the accessibility and delivery of mental health services in primary health care settings through interdisciplinary collaboration.

Four key elements that define collaborative mental health care:

1. Accessibility – increasing accessibility to mental health services; and effective collaboration does not require that the health care providers are located in the same place

2. Collaborative Structures – successful collaborative mental health initiatives recognise the need for systems and structures to support collaboration, including formal and



Collaboration

informal structures that define the ways in which people work together; and organising and creating systems that define who they agree to accomplish things together.

3. Richness of Collaboration – including knowledge transfer, involvement of partners from a wide range of disciplines and communication

4. Consumer centredness – ensuring that consumers are involved in all aspects of their care

Morley and Cashell 2017

Article lists a number of different definitions of collaboration:

• Involves multiple people interacting to achieve a common goal • Consists of social inputs and task inputs • Is ‘‘an active and ongoing partnership between professionals and institutions with

diverse backgrounds and mandates who work together to provide services’’ • Is a process that involves cooperation, communication, negotiation, trust, respect, and

understanding to build a synergistic alliance that maximizes the contributions of each participant

• Involves constructing both a collective action to address complex patient needs and an interprofessional team relationship involving respect and trust

• Is a process of working together, negotiating agreement and managing conflict, and both valuing and understanding one another

• Involves working together, shared planning over time, functioning cooperatively as colleagues and equals with respect and a view to find solutions together

• Is ‘‘a dynamic, transforming process of creating a powersharing partnership for purposeful attention to needs and problems (practice) to achieve likely successful outcomes’’

• Is ‘‘an efficient, effective, and satisfying way to offer health care services through a process by which interdependent professionals are structuring a collective action toward patient’s care needs’’

Common themes among these definitions suggest that collaboration is an integration of activities and knowledge that requires a partnership of shared authority and responsibility.

Four critical elements described by Sullivan provide a useful breakdown of behaviours and attitudes that, together, constitute collaborative practice in health care:

5. Coordination (working to achieve shared goals) 6. Cooperation (contributing to the team,

understanding and valuing the contributions of other team members)

7. Shared decision-making (relying on negotiation, communication, openness, trust, and a respectful power balance)

8. Partnerships (open, respectful relationships cultivated over time in which all members work equitably together)

Jenson & Potter 2003

The term collaborative cross system refers to the application of integrated intervention principles and practices jointly selected and administered.



Collaboration

Dedrick & Greenbaum 2011

Interagency collaboration has been broadly defined as “mutually beneficial and well-defined relationships entered into by two or more organizations to achieve common goals”

Additional defining characteristics of interagency collaboration have included (a) developing and agreeing to a set of:

a) common goals and directions, b) sharing responsibility for obtaining those goals, and c) working together at all levels of an organization to achieve those goals

Frey et al 2006

• Collaboration has a variety of definitions and names but is generally treated as meaning the cooperative way that two or more entities work together toward a shared goal.

• Collaboration can be seen as having a number of stages:

Bronstein 2003

• Interdisciplinary collaboration is an effective interpersonal process that facilitates the achievement of goals that cannot be reached when individual professionals act on their own

Australian Consensus Framework for Ethical Collaboration in the Healthcare sector 2018

Details procedural principles noting that collaborations and interactions should be characterised by:

• Honesty: Those engaged in collaborations are truthful in all their interactions. • Integrity: Those engaged in collaborations are alert to competing and conflicting

personal, professional and organisational interests and to the management of bias. • Reflexivity: There is ongoing critical reflection on the values, principles and evidence

underpinning collaborative judgments and actions. • Transparency: The processes of collaboration, and the values, principles and evidence

upon which decisions are made, are open to scrutiny • Inclusiveness and shared understanding: All relevant stakeholders should participate

in collaborations in order to learn from one another and work together respectfully to generate mutually agreed outcomes.

• Responsibility and accountability: Those involved in collaborative processes take responsibility for, are able to explain, and are accountable for, their actions and decisions.

• Reasonableness: Those involved in collaborations act, and make decisions, on the basis of rationales that are widely accepted as relevant and fair.

• Testability: The judgments and decisions made by those engaging in collaboration are open to independent verification and revision.

• Revisability: There are procedures in place for appeals and for revising collaborative judgments and decisions in the light of challenges to them.

• Oversight: There are mechanisms in place to ensure that the principles described above are given due consideration.



Collaboration

Brotherhood of St Laurence and the Australian New Zealand School of Government, 2018

This guide details that: “collaboration is a durable relationship based on a shared purpose, it is not just networking or sharing information.”

Gardiner 2005

The following description of collaboration is based on the work of both Follett and Gray:

Collaboration is both a process and an outcome in which shared interest or conflict that cannot be addressed by any single individual is addressed by key stakeholders. A key stakeholder is any party directly influenced by the actions others take to solve a complex problem. The collaborative process involves a synthesis of different perspectives to better understand complex problems. A collaborative outcome is the development of integrative solutions that go beyond an individual vision to a productive resolution that could not be accomplished by any single person or organization.

Thomson and Perry 2006

Collaboration is the act or process of “shared creation” or discovery. It involves the creation of new value by doing something new or different.

Five key dimensions of collaboration (see figure)

Petri 2010 Inter disciplinary collaboration includes three attributes:



Collaboration

• It is a problem focused process • It involves sharing – notably objectives, responsibility, decision making and power • It includes working together – denoting a sense of working together in cooperation

Van Eyk & Baum 2002

This article describes some of the findings of a research project that evaluated collaborative strategies adopted and trialled by a group of four publicly funded healthcare agencies in the southern metropolitan area of Adelaide (note this is not about mental health specifically – but rather health in general – parallel evidence).

Collaboration occurs at all levels of the health system. It may be project or issue based, long or short term, formally part of an agency’s work, or undertaken informally and in an ad hoc manner through the numerous linkages and networks of relationships between service providers to support the care of their individual clients. Linkages both within and between agencies are essential to their capacity to meet the needs of their clients

Public Service Commission 2016

In August 2016, the Public Service Commission (PSC) Advisory Board commissioned a review on collaboration in the NSW Public Sector. This Review focuses on collaboration in the Human Services sector. Since 2013, the drivers for collaboration in this sector to improve customer, delivery and community outcomes have been given fresh impetus by the Government’s commissioning and contestability agenda.

The Commission define collaboration as:

Collaboration is more than one party within the public sector or within and beyond the public sector working together in the areas of policy development, service design or service delivery. (Collaboration Blueprint).

Collaboration is a critical element in supporting any engagement or project that requires multiple skill sets and capabilities to deliver an outcome. It is required within organisations and teams, within a sector and when working across organisational boundaries

Tasmanian Department of Premier and Cabinet (date unknown)

Definition of collaboration

There is no universally accepted definition of collaboration and a range of terms, such as whole-of-government, joined up government, cross-cutting or integrated government have all been used to refer to this work. These terms are often used interchangeably.

The Australian Government uses the term ‘whole-of-government’, which was defined for the Australian Public Service in 2004 as:

“…public service agencies working across portfolio boundaries to achieve a shared goal and an integrated government response to particular issues. Approaches can be formal and informal. They can focus on policy development, program management and service delivery.”

Whatever the term used, the essential features of collaboration include:

• agencies working across traditional portfolio boundaries; • developing an integrated approach to a complex or cross-cutting issue; and



Collaboration

• sharing responsibility for an outcome, including the risks and rewards associated with the project.

El Ansari 2011

This paper highlights the need to standardise terminologies to assist in the delivery of integrated care. In relation to collaboration versus integration they highlight that:

some authors contend that collaboration is simply the act of working together, whereas coordination involves regulation of participants to produce higher-order functioning



Barriers

• Potential challenges in promoting collaborative practice may include systemic determinants which influence to what degree collaborative practice is possible.

• Within the team, and therefore potentially in control of the team, members may have different interests, goals, expectations, styles, and experiences which can complicate communication and generate conflict.

Opportunities

• The physical and organizational environment in which an interdisciplinary team operates can impact the degree and nature of collaborative interactions. Environment can be taken to include physical spaces, temporal arrangements, schedules, processes, organized activities, and communication tools that may either encourage or discourage effective team collaboration.

• Organizational structure can include the architectural considerations (physical structure, functionality, and aesthetics) and management considerations (defined relationships between team members and between teams) and has both formal and informal parts

• Distant, virtual, and asynchronous are examples of team types which may have reduced ability to collaborate.

• Even health care teams within a single building may be separated by space (work areas) and time (schedules); they may be asynchronous and virtual because of the prevalence of electronic communication (e-mail and other systems)

Darlington et al (2005).

Many failures of collaboration are not because collaboration cannot deliver improved services etc, but because effective collaborative relationships failed to develop because of professional level and agency level barriers; including:

• Respecting and having a positive view of the role and the workers of the other agency is a fundamental component of an effective collaborative relationship

• Professionals from different disciplines and/or working in different agencies may operate with different knowledge bases, discourses, and conceptual frameworks

• The absence of effective interagency structures and policies, including effective liaison and guidelines, has been highlighted as a barrier to collaboration. Without structures and policies that support and encourage interagency collaboration, individual workers find it difficult to initiate and maintain cross-organizational relationships



Collaboration

• The adequacy and allocation of resources have also been identified by many authors as important factors. Inadequate resources leave workers without time to establish and maintain contact with other agencies and create ‘gatekeeping disputes’

• Open communication is one of the most critical aspects of effective collaboration

Five potential barriers to communication (based on authors study):

Factor 1: Gaps in interagency processes. This factor comprised nine items related to the structures, policies, and procedures which are not present but which would facilitate collaboration (e.g., lack of information on services available, lack of knowledge about the role of workers in the other agency, and lack of culture of liaison).

Factor 2: Inadequate resources. This factor comprised three items related to resource allocation: a lack of time, high workloads, and lack of appropriate community resources.

Factor 3: Professional knowledge domains and boundaries. This factor comprised six items that described points of conflict surrounding issues of professional knowledge and boundaries in interagency collaboration (e.g., differing theoretical bases, feelings of ownership of clients, conflicting aims and expectations, and differing perceptions about who is the primary client).

Factor 4: Unrealistic expectations The factor was defined by two items designed to assess whether respondents felt that others had unrealistic expectations of their authority: child protection workers have unrealistic expectations about mental health workers’ authority to act, and mental health workers have unrealistic expectations about child protection workers’ authority to act.

Factor 5: Confidentiality. This factor included two factors pertaining to issues of client confidentiality and different practices regarding confidentiality, defined this factor.

Widmark et al (2011)

Structural barriers to collaboration include differences in the regulatory, financial, and administrative boundaries, and

Cultural impediments consist of the various ways that the needs of individuals are considered, which are often a product of educational and organizational cultures

In sum, research concerning collaboration between different sectors have demonstrated the following:

• joint management of collaborating organizations is important • it is important for organizations to have a common interest, if they are to interact

and have common goals • managers must achieve and maintain collaboration • it is vital that professionals are motivated for the joint task • trust should exist or be built between the professionals involved; • collaboration is supported and maintained by shared responsibility for

management, shared resources, and meetings between the stakeholders

Brotherhood of St

• Successful collaboration hinges on trust which must be built up. • Engage in open and honest dialogue about what organisations want to achieve



Collaboration

Laurence and the Australian New Zealand School of Government, 2018

• Expect to pool knowledge and resources and share both risks and rewards • Build on common ground • Demonstrate commitment • Combine strengths

Marek et al 2014

These authors cite the work of Mattessich and Monsey who conducted a meta analysis of effective collaboration practices – which includes 20 factors organised into six categories:

1. Environment 2. Membership characteristics 3. Process/ structure 4. Communication 5. Purpose 6. Resources

Gardiner 2005

The author provides ten lessons in having effective collaborations:

• Know yourself - individuality mediates our models...Each person in the organization will have a somewhat different mental model of how the collaboration will proceed.

• Learn to value and manage diversity • Develop Constructive Conflict Resolution Skills – conflict can hinder and facilitate

collaboration • Use Your Power to Create Win-Win Situations • Master Interpersonal and Process Skills • Recognize that Collaboration is a Journey • Leverage Multidisciplinary Forums to Increase Collaboration • Appreciate that Collaboration Can Occur Spontaneously • Balance Autonomy and Unity in Collaborative Relationships • Remember that Collaboration is Not Required for All Decisions

Petri 2010 For interdisciplinary collaboration to be successful – support is required from the individual and the organisation / administration. With organisational or administrative support being of primary importance.

Van Eyk & Baum 2002

This study – identifies the following barriers (along it is in relation to health generally not mental health specifically)

The barriers to collaboration have been identified in the literature as being:

• lack of time and resources, • funding issues, • lack of knowledge and • poor information flow, • lack of personal links and trust, • philosophical differences,



Collaboration

• professional issues, and • staff and organizational changes.

Time pressures can discourage flexibility and reflection, and are more likely to foster a very task-oriented, less reflective approach. Task orientation is important for participants to feel that they have achieved outcomes from an activity, but reflection and flexibility are essential to ensure that the tasks being focused on are actually the shared priorities of the group.

The strength and value of collaborative partnerships is reliant on the level of commitment of each of the stakeholders. Territorialism and a lack of a systems view can undermine collaborative efforts, as can a lack of support from the agencies’ leadership, and a lack of clear boundaries and agreed goals for the process.

Australian Research Alliance for Children & Youth

Public Service Commission 2016

The Commission report details that true collaboration requires fundamental change from all parties, including:

• Work to a shared vision and outcomes, and adapt as this changes at different stages of the engagement lifecycle.

• Ensure any outcomes and vision are centred around the end user and community, and jointly determine how each party can contribute in a coordinated fashion.

• Collaborate early and often, with a focus on jointly defining and solving critical problems: all parties are prepared to come to the table not knowing what the answers are.

• Deliver using a common ‘language’ of processes, practices, frameworks and systems. • Bridge organisational boundaries across a number of dimensions including sharing

Intellectual Property, contractual risk and personnel to achieve the desired outcomes. • Work with clear roles and expectations across complex thinking and delivery

challenges. • Share capabilities and leverage each party’s strengths and support areas of weakness. • Take accountability for success and failure and ensure that those with accountability

are adequately set up to succeed.

These requirements are as much about shifting culture and mindset as they are about skills, processes and practices. It is about surrendering control. All parties need to be prepared to change their operating model and follow through on that change to deliver in a collaborative way. The preparedness to give up organisational autonomy, power and established ways of operating to deliver in a new way is a key issue.



Collaboration



Instruments designed to quantitatively score collaboration often focus on specific professions (often nurse-physician), mono-disciplinary teams, or highly specific teams and work areas.

Other tools focus on assessing quality of interprofessional education (IPE) rather than team behaviours. Few tools are both publically available and accompanied by psychometric testing to demonstrate validity.

The following are the seven published tools with some psychometric analysis.

• Index of Interdisciplinary Collaboration], • Multidisciplinary Collaboration instrument • Interprofessional Perceptions Scale • Role Perceptions Questionnaire generic form • University of Western England Interprofessional Questionnaire • Modified Index of Interdisciplinary Collaboration • Assessment of Interprofessional Team Collaboration Scale (AITCS).

These tools are questionnaires eliciting perceptions of collaborative behaviour. Direct measures of collaborative behaviour may be more difficult or time consuming to obtain, particularly because many behaviours would need to be directly observed and could be difficult to quantify accurately

Dedrick & Greenbaum 2011

Several approaches have been used to measure collaboration, including:

• network analysis, which involves mapping formal and informal links between collaborators



Collaboration

• semi-structured interviews of staff by knowledgeable experts who then make global ratings of interagency collaboration, and

• self-report questionnaires that measure informants’ perceptions of their organization’s level of collaboration.

Interagency Collaboration Activities Scale – is a self-report questionnaire to measure the extent to which individuals perceive their agencies are collaborating with other agencies

Marek et al (2014)

This article acknowledges the difficulty in evaluating collaboration effectiveness – reasons for this include:

• lack of empirically validated tools, • undefined or immeasurable community outcomes, • the dynamic nature of coalitions, and • the length of time typical for interventions to effect community outcomes

Their study developed the Collaboration Assessment Tool (CAT); which consists of 69 items pertaining to the seven factors (context, members, process / organisation, communication, function, resources and leadership)

Walters et al 2016

Whilst not specific to mental health – this study undertook a review of measurement of collaboration tools; its purpose was to evaluate and compare measurement properties of instruments that validate collaboration within health care settings (note that it is more relevant to collaboration at the patient level than the system level). Twenty one studies of 12 instruments were included in the review.

Measurement objectives included:

Investigating beliefs, behaviours, attitudes, perceptions and relationships associated with collaboration across teams or assessing internal participation of both teams and patients.

Most of the studies included in this review are relevant only to the health care setting; apart from the Assessment of Interprofessional Team Collaboration Scale – which was developed from the need to assess collaborative relationships and is based of four key collaborative domains

• Co-ordination • Co-operation



Collaboration

• Shared decision making • Partnerships

The scale is a 47 item questionnaire - and is available here http://swostroke.ca/wp-content/uploads/2015/12/AITCS-May-09.pdf

Noone et al 2017

The Collaboration Health Assessment Tool (CHAT) is described as a simple yet powerful online resource for measuring how collaborators are working together now and into the future. CHAT gives users the option of either interacting with the tool on a “one off” basis or by setting up an account with (or without) their collaborators. Both options will generate a series of component scores and an overall “health score” for the collaboration. If desired, CHAT can also be set up to produce scores for each group working in the collaboration (e.g. Backbone, working group, community group). Note it is for collaborations more generally not health or mental health specifically.

CHAT is said to provide collaborating initiatives with the applied tools they need to meet their goals. Users receive:

• A score for each of the eight dimensions of collaboration and an overall score. Scores are based on a traffic light system and can be produced for the whole collaboration as well as for individual groups working within it

• Feedback tailored to the CHAT score. CHAT will generate broad guidelines on how specific elements of the collaboration could be enhanced.

• A printable report. A collaboration’s results and feedback can be printed as a report for easy dissemination to your stakeholders.

• The capacity to track progress over time.

Using the collaboration’s unique key (automatically provided upon registration) will allow collaborations to use CHAT now and in the future.

http://swostroke.ca/wp-content/uploads/2015/12/AITCS-May-09.pdf

http://swostroke.ca/wp-content/uploads/2015/12/AITCS-May-09.pdf



Integration

1. Definitions

WHO 2016

Integrated health services are health services that are managed and delivered in a way that ensures people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services, at the different levels and sites of care within the health system, and according to their needs, throughout their whole life.

NSW Health 2018

Integration of care is an approach that aims to deliver seamless care within the health system and its interface with social care. It places people at the centre of care, providing comprehensive wrap around support for individuals with complex needs and enabling individuals to access care when and where they need it. A more integrated health care system is easy to use, navigate and access. It is responsive to the specific health needs of local communities, providing them with more choice and greater opportunities to actively engage with the health system.

Dalton et al 2018

Article cites the following definition of integrated care from WHO:

“A coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between cure and care sectors”

Suggests four aims of integrated care:

• improving the experience of care • improving the health of populations • reducing per capita costs of health care • improving the experience of the health workforce

Calciolari et al 2016

Outlines key information on the Project INTEGRATE Framework, which provides an evidence-based understanding of the key dimensions and components of integrated care.

Suggests seven dimensions of integrated care:

1. Person centred care – refers to improving someone’s overall well-being [not focusing solely on a particular condition/disease] through active engagement of service users [patients, carers etc] as partners in care.

2. Clinical Integration – refers to how care services are coordinated and/or organised around the needs of service users

3. Professional integration – refers to the existence and promotion of partnerships between professionals to work together [e.g. in teams]

4. Organisational integration – refers to how providers come together to deliver care services in a linked-up fashion across partner organisations

5. Systemic integration – refers to how the care system provides and enabling platform for integrated care, such as through alignment of key systemic factors [e.g. financing mechanisms, regulation]

6. Functional integration – refs to the capacity to communicate data and information effectively within an integrated care system


7. Normative integration – refers to the extent to which different partners in care developed and shared a common reference frame on care integration [e.g. vision, norms, values]

Read, et al 2019

Integrated care is care with a person-centred focus and a population health approach.

• It implies service changes to ensure care is co-ordinated around the needs of the people involved (patient, carer, family member or population) to overcome fragmentation of service delivery and improve quality and efficiency.

• Integrated care aims to improve access, quality and continuity of treatment, reduce fragmentation of services and improve health

• outcomes (including consumer perceptions of outcomes) through service innovation.

• Needs to involve cross-sector collaboration.

The dimensions and sub-elements of integration (see figure below) are considered appropriate for successful integrated care implementation across countries and population groups regardless of the health condition or care group issue.

Kodner 2009

Acknowledges the lack of common definition. Identifies the following different views of integrated care (Adapted from Lloyd and Wait 2006)

Patients: Easy access and navigation; seamless care

Providers: Interdisciplinary teamwork; co-ordination of tasks, services and care across professional and institutional boundaries

Managers: Oversight of combined funding streams; co-ordination of joint performance targets; supervision of enlarged and professionally diverse staff; management of complex organizational structures and inter-agency relationships; building and maintenance of shared culture

Policymakers: Design of integration-friendly policies, regulations and financing arrangements; valuation of systems/programs on holistic basis

Notes integration is:

• Commonly built around related notions of continuity of care and coordinated care. • Designed to create coherence and synergy between various parts of the healthcare

system in order to enhance system efficiency, quality of care, quality of life and consumer satisfaction, especially for complex and multi-problem patients

• or clients. • A principal driver of reform due to the need to continue providing affordable, quality

healthcare; governments have no choice but to restructure the health system in ways that enhance efficiency and reduce fragmentation


Lewis, et al. 2009

This report by the NHS is mostly concerned with service level integration; however this diagram provides a definition of systematic integration.

NSW Health 2018

Review of Mental Health Commission of NSW Report to Parliament

Integrated care involves effective and efficient care for the health needs of the whole person, in partnership with the individual and their carers and family. This emphasises greater communication and connectivity between health care providers in primary care, community and hospital settings, and government and nongovernment community-based services close to home.

Highlights the availability of agency and community network support services such as employment, education, housing and justice are critical in ensuring that people who experience mental illness have access to a sustainable continuum of care.

Curry & Ham 2010

States there are many competing definitions of integration and integrated care.

Suggests integration can occur at three levels:

• The macro level - providers, either together or with commissioners, seek to deliver integrated care to the populations that they serve.

• The meso level - providers, either together or with commissioners, seek to deliver integrated care for a particular care group or populations with the same disease or conditions, through the redesign of care pathways and other approaches.

• The micro level - providers, either together or with commissioners seek to deliver integrated care for individual service users and their carers through care co-ordination, care planning, use of technology and other approaches.

Brown et al 2004

Integration describes types of collaboration, partnerships or networks whereby different services that are usually autonomous organizations, work together for specific community residents to improve health and social care. In order to work together effectively, they each may incur resource costs.

Goodwin 2016

Acknowledges there have been many definitions – driven by differing professional points of view [e.g. clinical vs managerial].


The most commonly used definitions demonstrate two principle characteristics of integrated care as a concept.

• First, it must involve bringing together key aspects in the design and delivery of care systems that are fragmented (i.e. ‘to integrate’ so that parts are combined to form a whole).

• Second, that the concept must deliver ‘care’, which in this context would refer to providing attentive assistance or treatment to people in need. Integrated care, then, results when the former (integration) is required to optimise that latter (care).

Typically conceptual frameworks designed to increase understanding of integration have examined:

• the type of integration (i.e. organisational, professional, cultural, technological); • the level at which integration occurs (i.e. macro-, meso- and micro-); • the process of integration (i.e. how integrated care delivery is organised and

managed); • the breadth of integration (i.e. to a whole population group or specific client group);

and • the degree or intensity of integration (i.e. across a continuum that spans between

informal linkages to more managed care co-ordination and fully integrated teams or organisations).

Integrated care takes a number of key forms, including : • Horizontal integration. Integrated care between health services, social services and

other care providers that is usually based on the development of multi-disciplinary teams and/or care networks that support a specific client group (e.g. for older people with complex needs)

• Vertical integration. Integrated care across primary, community, hospital and tertiary care services manifest in protocol-driven (best practice) care pathways for people with specific diseases (such as COPD and diabetes) and/or care transitions between hospitals to intermediate and community-based care providers

• Sectoral integration. Integrated care within one sector, for example combining horizontal and vertical programmes of integrated care within mental health services through multi-professional teams and networks of primary, community and secondary care providers;

• People-centred integration: Integrated care between providers and patients and other service users to engage and empower people through health education, shared decision-making, supported self-management, and community engagement; and

• Whole-system integration: Integrated care that embraces public health to support both a population-based and person-centred approach to care. This is integrated care at its most ambitious since it focuses on the multiple needs of whole populations, not just to care groups or diseases.

Two new ideas to emerge in more recent years are:

• The recognition that engaging and empowering people and communities should be a central component to any integrated care strategy;

• Integrated care strategies might be most powerful where they become population-oriented and focused on promoting health, for example by bringing together health and social care with other players such as housing, schools, community groups, industry, and so on.


Both these ideas see integration as a way of bringing community assets together to promote health and wellbeing to populations, so taking the potential focus of integrated care beyond specific service models or the propensity to individualise the focus around, for example, disease management programs and care pathways.

Keast 2011

Uses the term ‘joined up’ to refer to integration.

Joined-up approaches draw on either vertical or horizontal integration dimensions in achieving their purpose and are often described as “topdown” or “bottom-up” models:

• Top-down integration refers to initiatives emanating from the authoritative core, usually the political or strategic leadership levels, which flow down to management and service levels. Top-down initiatives are pursued principally for the objectives of efficiency and coherency and entail the use of mandate, incentives, and other formalized integration mechanisms.

• Bottom-up integration describes initiatives emerging voluntarily from the service delivery front, often driven by scarce resources and uncertainty in the organizational environment as well as a desire for enhanced service outcomes.

Notes that three levels of integration activity have been identified by others:

• macro level of policy, strategic planning and financing decisions; • meso or middle level involving relationships among services in a region and

integration at the managerial level; • micro level, which concerns the direct relationships between practitioners and the

people they assist

However, cites a key limitation to past frameworks is they don't adequately reflect the complex and often layered approaches generally adopted by joined-up initiatives. In response, a number of authors have combined various elements to produce a multi-dimensional integration framework. For example the one depicted within this summary.

Strandberg-Larsen 2011

Via a review of literature the article distinguishes between two distinct conceptual subcategories which can be identified within the literature referring to integrated healthcare

• an organizational structure that primarily follows economic imperatives (e.g. that unites a financing group with all providers – from hospital, clinics, and physicians through home care and longterm care facilities to pharmacies) or to

• a way of organizing care delivery – by co-ordination of different activities to ensure harmonious functioning – ultimately to benefit the patients in terms of clinical outcome

A key characteristic in both of the above is that the provider is not a single facility (e.g. a hospital or general practice) but a network of providers accountable to its eligible patients.


Drawing on a review of the literature on definitions and concepts, suggests the field of integrated healthcare delivery has a number of different yet inter-related and partly overlapping perspectives, namely:

• Patient perspective: focus is on the patient’s experience with a single provider or the journey of the patients through a system of providers.

• Organizational and management perspective: focus is on strategic development and on intra- and interorganizational co-ordination and comprises arrangements such as case management and multidisciplinary teams.

• Logistic perspective: focus is on the recommended routes of patients through the system and the links between its component parts.

• Policy perspective: as a policy concept integrated healthcare delivery refers to optimizing the healthcare system as a “combined whole” through respective legislation, regulation systems and policy programmes.

• Economic perspective: from a microeconomic perspective focus is on efficiency in terms of gaps and overlaps in service delivery (94), and from a macroeconomic perspective the economic imperative focuses on the potential benefits of healthcare alliances created through mergers and acquisitions.

• Clinical practice perspective: focus is on coordinating patient care services across people, functions, activities, and sites over time so as to maximize the value of services delivered to patients seen from a clinical viewpoint. Shortell et al. refer to this as clinical integration.

• Public health perspective: focus is on providing the population and/or high risk groups within the population with services needed for optimization of population health. This perspective will often go beyond the realm of healthcare, and co-ordination of services will therefore also be expanded to include social care services or similar.

El Ansari, 2011

This paper highlights the need to standardise terminologies to assist in the delivery of integrated care. In relation to collaboration versus integration they highlight that:

some authors contend that collaboration is simply the act of working together, whereas co-ordination involves regulation of participants to produce higher-order functioning

Durban et al 2006

At the systems level, integration is defined as providers and agencies within and across service sectors working collaboratively and efficiently to provide a coordinated continuum of services to a defined population, and are held clinically and fiscally responsible for the health status of that population efforts of a program or network. The premise is that greater integration of service delivery will result in improved continuity of care for clients.


Shaw et al 2011

This paper presents information on what is integrated care; It also provides the following definition in relation to integration:

Integration is the processes, methods and tools of integration that facilitate integrated care. Integration involves connecting the health care system (acute, community and primary medical) with other service systems (such as long-term care, education or housing services)

This differs from integrated care, which is defined as the following:

The patient’s perspective is at the heart of any discussion about integrated care. Achieving integrated care requires those involved with planning and providing services to ‘impose the patient perspective as the organising principle of service delivery’.

In the literature five main types of integration are typically described – see beside:

NSW Government 2018

The Integrated Service Response (ISR) is a NSW Government initiative that aims to build the capacity and capability of mainstream services to deliver sustainable, multi-agency service responses for people with disability who have complex support needs. The ISR Operations Manual provides the following definitions:

• Integration is achieved when links between services draw them into a single system. • Collaboration occurs when multiple services work together in complex ways to

change the way the service system operates. • Co-ordination occurs when services form partnerships to deliver supports to the same

client.

NSW Government 2018

Citing the work of Inca Consulting in a report commissioned by the NSW Department of Premier and Cabinet, there are a number of components to effective integrated practice. These include:

• systems for sharing information, particularly given privacy/professional confidentiality • system based problem identification • shared aims and definitions about the needs of people with disability • shared knowledge and understanding about the assessment of risk • respect for professional expertise across disciplines and agencies • adequately trained and professional staff • multidisciplinary collaboration • willingness to sacrifice aspects of professional autonomy to achieve practice unity • willingness to adapt organisational practice and procedures to achieve outcomes • practices and protocols that safeguard culture, inclusion, access and equity


• commitment to continuous improvement with data collection and monitoring.

Heenan & Birrell, 2006

This paper studies the mechanisms for the integration of social services with health (not specific to mental health) it identifies the key issues associated with integration.

The most distinctive features of integration was that all professionals were employed by the same organization, have the same source of funding, share the same goals and objectives and work alongside each other.

It was noted that integration exists on three main levels:

1. strategic, where the planning of health and social services is undertaken in a holistic way;

2. operational, with the aim of providing a seamless service; and 3. individual, where professionals from health and social services work together to

ensure that the needs of the individual are addressed.

The positive outcomes from integrated working through programmes of care include: integrated planning and commissioning, professionals working together and integrated management

Fine et al 2000

Through a review of published literature and documents, the article summarises information related to coordinated and integrated human service delivery models in Australia and overseas.

Highlights that despite the level of interest in improving co-ordination of human services, there remains vagueness and fundamental disagreement in defining the most frequently used concepts such as ‘collaboration’, ‘co-ordination’ and ‘integration. Suggests that an increasingly widely accepted way of thinking of these phenomena is to understand the integration of services as a sort of continuum or scale, as set out in the diagram below [adapted by the NSW Government ISR service].

Fine suggests that full integration creates new programs (eg managed care services) or units (such as hospitals) where resources are pooled and that the fully integrated program gains control of resources to define new benefits and services that it controls directly, rather than better coordinate existing services.

Fine’s review identified ten different service integration models – each with some unique and some overlapping features/components: Service Hubs; Multi- Purpose Services; School linked services; One stop Shops for Information and Referral; Innovative Case Management Approaches; Social Partnerships; Formal Networks; Community Level Integration; Collaboration Approaches; and The Merging of Government Departments.



NSW Health 2018

The NSW Health Strategic Framework for Integrating Care identifies nine enablers that are required to implement and support the integration of care in NSW.

1. Engagement - supports empowering people, families and their carers to influence their health care journey and to meet individual and community needs and aspirations.

2. Partnerships - effective working partnerships and relationships across the health system and its interface with social care promote clear roles, accountability, trust, shared decision-making and information sharing between partners.

3. Leadership - strong clinical and executive leadership and management are crucial enablers of the integration of care. Leaders are important role models of the mindsets and behaviours that support the successful integration of care. Empowering local teams to be leaders on the ground also supports more effective integration of care.

4. Culture - integrating care requires a shift in thinking to create a health service culture that is centred on the needs of the person, is proactive rather than reactive, operates as one integrated system, and increases multidisciplinary and multi-system care.

5. Governance - governance supports effective decision making and clear accountabilities when integrating care. Effective governance structures are especially important to support partnerships within and between health care organisations and their interface with social care organisations

6. Funding - funding mechanisms influence system wide implementation of integration of care initiatives. Incentives can influence the behaviour of system participants including service providers and clinicians. Additionally, ongoing incentives which are built into the system (rather than temporary incentives) play a critical role in promoting and supporting the integration of care

7. Capability - capability recognises that staff require a specific skillset to deliver care that is integrated. Different capabilities are required across all aspects of the integration of care from program design and management, through to the delivery of health and social care and the measurement of outcomes associated with the integration of care.

8. Technology - technology supports and facilitates the integration of care. Technology provides important architecture to support many of the activities critical to integrating care such as information sharing. This includes systems, which are critical to embedding the integration of care into business as usual.

9. Information - information plays an important role in ensuring the seamless provision of care is provided in the most effective manner. The sharing of information between service providers and clinicians facilitates seamless care for consumers. Accurate and effective information analytics ensures integrated care is targeted to the people who will benefit most and supports the continuous improvement of the system.

WHO 2016

In its Framework on Integrated People Centered Health Services, the WHO proposes five interdependent strategies to reform health services such that they become more integrated and people-centred:

(1) empowering and engaging people and communities - providing the opportunity, skills and resources that people need to be articulate and empowered users of health services and advocates for a reformed health system.

(2) strengthening governance and accountability - requires a participatory approach to policy formulation, decision-making and performance evaluation at all levels of the health system, from policy-making to the clinical intervention level.


(3) reorienting the model of care - ensuring that efficient and effective health care services are designed, purchased and provided through innovative models of care that prioritize primary and community care services and the co-production of health.

(4) coordinating services within and across sectors - integration of health care providers within and across health care settings, development of referral systems and networks among levels of care, and the creation of linkages between health and other sectors. It encompasses intersectoral action at the community level in order to address the social determinants of health and optimize use of scarce resources

(5) creating an enabling environment - in order for the four previous strategies to become an operational reality, it is necessary to create an enabling environment that brings together all stakeholders to undertake transformational change. This complex task will involve a diverse set of processes to bring about the necessary changes in leadership and management, information systems, methods to improve quality, reorientation of the workforce, legislative frameworks, financial arrangements, and incentives.

Attainment of these five strategies cumulatively will help to build more effective health services; lack of progress in one area will potentially undermine progress in other areas.

Read et al 2019

Key barriers to integrated care were identified as:

• Services with a major role to play in determining health outcomes (healthcare, social care and education) are administered by different government departments with disparate funding, goals and responsibilities. Where there are notable successes [noted as Scotland and Canada] the provision of health and social services are jointly administered.

• Limited interdepartmental collaboration. • The complexity of the healthcare system • Fee-for-service funding arrangements which reward the quantity of services rather

than the quality. Such arrangements overlook population health needs and discourage collaboration to address service user needs and outcomes

Threats to integrated care were noted as rising costs; problems with the structure and integration of the healthcare system; changing demographics and an ageing population; problems of equity; risks to the health of minorities and other groups; and issues with the efficiency and sustainability of the overall health system and its workforce.

Key enablers to integrated care were identified as: • The ability to share information safely and securely amongst care professionals. [the

paper notes that an IT platform to achieve this was not able to be identified in the Central Coast context]

• Outcomes-based commissioning that places the emphasis on achieving the desired outcomes for the service user (rather than the more usual measure of performance by activity).

• Taking a population health approach, informed by data, health and population needs analysis

• Co-design of stakeholders in service design • Building capacity to implement integrated care, including skills for implementation in

partnered multi-agency collaborative settings and joint training in the use of a consistent framework and change management approach

• Drawing on evidence and international experts in integrated care to inform planning, implementation and review of progress

• The willingness and commitment of key staff


• The importance of leadership, good communication, relationship building, and cultural transformation.

Suter et al 2009

A systematic review was conducted with the goal of summarizing the current research literature on health systems integration, the study (which focuses on health not mental health), found that there were 10 principles that were most often presented:

• Comprehensive services across the continuum of care • Patient focus • Geographic coverage and rostering • Standardised care delivery through interprofessional teams • Performance management • Information systems • Organisational culture and leadership • Physician integration • Governance structure • Financial management

Processes and strategies must be implemented that align with and support these guiding principles and integration structures (such as co-location of services, information systems); otherwise, the desired outcomes of integrated care may not be achieved.

Two of these principles that have most relevance to system integration include:

• Under organisational culture and leadership - Implementation and operation of an integrated health system requires leadership with vision as well as an organizational culture that is congruent with the vision.

• Governance structures - Bringing together organizations and services into an integrated health system through contractual relationships or networks typically requires development of governance structures that promote co-ordination

Smyth 2009

Identifies governance as a key determinant of successful integration. Suggests that governance provides the framework and leadership for momentum and support to accomplish the integration of services. Key points:

• Integration crosses organisational and jurisdictional boundaries and involves multiple stakeholders in decision making processes about how integration will be achieved. This requires integrated decision making which is extremely complex due to multiple partners; organizational jurisdictional, and public and private provider boundaries; unique cultures; finite resources; and multiple bodies of professional knowledge and practices as well as business processes.

• Strong and committed executive and medical leadership is essential to enable stakeholders to move beyond past history and experience, and step outside the silos and away from the protection of familiar turf, organizations, professions or jurisdictions.

Curry and Ham 2010

Suggest that the performance of macro level integrated systems rests on a set of core of factors (based on examining a broad range of integrated systems in the United States)

• multispecialty medical groups in which generalists work alongside specialists to deliver integrated care

• aligned financial incentives that avoid the perverse effects of fee-for-service reimbursement, encouraging the prudent use of resources and promoting quality improvement


• information technology that supports the delivery of integrated care, especially via the electronic medical record and the use of clinical decision support systems

• the use of guidelines to promote best practice and reduce unwarranted variation in care

• accountability for performance through the use of data to improve quality and account to stakeholders through public reporting

• defined populations that enable doctors and the wider health care team to develop a relationship over time with a ‘registered’ population

• a physician–management partnership that links the clinical skills of health care professionals and the organisational skills of executives

• effective leadership at all levels with a focus on continuous quality improvement • a collaborative culture that emphasises team working and the delivery of patient

centred care.

Brown et al 2004

Key barrier to integration is that health, education, social, leisure, faith and correctional services are funded as separate entities by autonomous agencies.

Cites examples of success due to innovative funding regimes – including the UK Health Action Zones which receive block funding for health, education, social and other services, Providers are expected to partner and collaborate to provide comprehensive, efficient services with these funds, and any savings are kept within the Health Action Zone.

Raynor 2009

• Staff are conditioned by the organisations in which they work, and cultural divisions between primary and secondary care and between health and social care have to be addressed

• Poor relationships between primary and secondary care are widespread. Mistrust and antagonism are often built upon historical battles over resources, with a common perception that secondary care has received a disproportionate share. Unless these relationships are addressed, the integration process will be dominated by disputes over money and fights to rebalance past injustices.

• Senior leadership is essential for creating a shared vision and setting out the principles and framework for integration.

• Training and mentoring for staff • Most current performance standards are measures of individual organisations within the

system, and there are few measures that cross organisational boundaries and follow the whole patient pathway across health and social care. System-wide performance measurement is an area that requires new methodologies for data capture and reporting.

Keast 2011

Article focusing on ‘joined up’ ways of working to achieve integration. Distils a core set of practices deemed as necessary for joined-up working as outlined below.


Strandberg-Larsen 2011

Cites Shortell et al who identify that four factors are important to have in place to achieve internal organization-wide impact on integration:

• The overall organizational structure of a healthcare system; • The technology available, including skills and training, and also health information

technology; • A management strategy that gives emphasis to achieving integration; • Culture, which refers to the underlying beliefs, values, norms and behaviours of the

system which either supports or inhibits co-ordination activities

Mental Health Commission of NSW 2016

Position paper relates to Health justice partnerships (HJPs) – which are early intervention programs recognising the complexity of disadvantage and occupy the space where health and social justice issues overlap. HJPs provide integrated, person-centred services for individuals to overcome structural barriers that negatively impact on a person’s quality of life and to advocate for systemic change.

The paper identifies the following essential conditions as essential to starting, maintaining and growing an HJP are listed below.

• Leadership/ champion • Relationships:

o With the people accessing the service o Between professionals

• Multi-disciplinary/ generalist professionals • Flexibility/ non-traditional approach • Organisational commitment characterised by:

o Authorising environment o Formalised agreements o Nominated points of contact o Culture of support

NSW Government 2018

The Integrated Service Response Operations Manual Development identifies the following requirements to deliver an integrated response:

• Facilitate a cross-agency collaboration approach to issues resolution including clarifying the responsibilities of relevant agencies and removing duplicate processes

• Ensure all agencies that need to be part of the solution are engaged • Coordinate teams for delivery of solutions • Facilitate cross-agency case conferences and discussions • Leverage existing agency relationships • Use the governance arrangements to raise issues such as local and systemwide

barriers to integration • Mentor Agency Leads and confirm when lead responsibility needs to be designated to

support resolution • Access a small amount of brokerage funding to build local capability, in exceptional

cases. • Facilitate sharing and agreement of information between relevant stakeholders • Inform, influence and reinforce service roles and responsibilities • Raise issues within service systems by accessing escalation pathways • Embed learning frameworks to streamline the approach for management of similar

cases and/or issues. • Reinforce integrated service delivery as a core responsibility of all service systems.


NSW Government 2018

Cited by the ISR is the work of Inca Consulting in a report commissioned by the NSW Department of Premier and Cabinet which identifies that barriers to effective integrated practice include:

• uncertainty about whether the service will improve outcomes • insecure ongoing funding of any partner • conflicting aspirations of different parts of the system • additional obstacles associated with NGO service delivery • information sharing • tensions associated with poorly defined roles and responsibilities / inadequate

mechanisms for resolving issues • flawed assumptions or unrealistic expectations • rural and remote factors.

Fine et al 2000

Enablers identified through a review of ten integrated care case studies included:

• Co-locating existing services and combining services. • Linking services through assessment and client assignment processes. • Community Consultation • Generic program indicators rather than departmental specific indicators. • The appointment of a facilitator with appropriate skills and abilities • Commitment at a senior level • Sufficient time to develop integration initiatives (and related implications for longer

term funding) • Establishment of locally based social partnerships of local community members,

representatives of existing state government and non-government service providing organisations.

• Commitment and support from senior levels of government • Clear objectives and achievable Goals • Funding and administrative arrangements that support integration.

Care Quality Commission

A review of 20 local health and care systems in England undertaken to better understand how service are working together to meet the needs of older people who move between health and care services identified the following barriers to achieving integration:

• There was good intent among organisations to work together to a common plan, but in reality most were focused on their own goals.

• Leaders were not accountable for the outcomes of their wider system, beyond the accountabilities of their individual organisations. Performance management was based on the specific responsibilities of each organisation, rather than outcomes for older people. Information about people was collected by each organisation for its own purposes, which prevented important information being shared effectively across all those involved in a person’s care.

• Workforce planning by each organisation operated in isolation to others in their area. • A regulatory and oversight framework focused only on individual organisations.


Kodner 2009 Notes that the accumulating evidence on effectiveness is indirectly derived from studies of different models and separate components (e.g., case management, disease management, etc.). States there is less certainty with respect to which bundle of strategies produces the


best results or whether integrated care generates cost savings, at least in the long run. Suggests the need for much more sophisticated work

to expand the evidence base on integrated care.

Brown et al 2004

Describes a three-dimensional model of service integration and introduces the Human Service Integration Measure that quantifies the extent, scope and depth of integration as perceived by local service providers.

The measure is an Excel based tool that identifies specific services that are participating in a program of care and then measures three aspects of integration:

• Extent of integration: the identification of services and the number of services within a number of programs or sectors involved in the partnership

• Scope of integration: the number of services that have some awareness or link with others

• Depth of integration: the depth of links among all services and each service, along a continuum of involvement where non-awareness = 0, awareness = 1, communication = 2, co-ordination =3, collaboration = 4.

The model was piloted in two children’s programs. Findings indicated community experts on integration found the measure helpful in determining which services were collaborating well and which were not.

It compares the measure with Weiss’s partnership synergy questionnaire and notes that each of these models and questionnaires are measuring different components of integration and that neither measure on its own would evaluate the complete nature of functioning and the scope and depth of integration efforts of a program or network. Accordingly they recommend the use of both measures.

Durban 2006

Paper that aims to summarize the evidence on the association between systems integration and continuity and identify strategies associated with increased continuity.

The research approach used a systems integration logic model to provide a common framework, language and set of indicators for describing the six systems under study and assessing their impact. Indicators were as follows:

• System organization—the management structure, the service sectors to be integrated and the resources provided

• System performance—the extent to which a full continuum of services and supports is available, the extent and nature of inter-agency linkages, and the strategies in place to bring services together

• Service outcomes—the continuity of care experienced by clients • Clinical and quality of life outcomes—improvement in client symptoms, function and

quality of life • Community context—e.g., mental health law, social and health expenditures, vacancy

rates.

The research demonstrated a positive association between systems integration and client continuity of care. Better results were obtained in systems characterized by stronger management arrangements, fewer service sectors, and system wide implementation of intensive case management and centralized access to services.


A noted limitation was that the reviewed studies were limited by their use of simple, aggregate measures of service use as indicators of continuity of care.

Keast 2011

A review of eight joined-up integration initiatives and numerous sub-cases conducted within and across the Queensland government and nongovernment sectors between 2000 and 2010 found that the most successful endeavors, in terms of both impact and sustainability:

• have been strategically designed to meet their purpose matching the nature of the problem or intent with the correct level of connection and the right integration mechanisms

• Extended their membership to government and non-government actors • have a strong management driver role • have augmented personal relationships with vertical connections to authority, thus

ensuring ongoing legitimacy and access to resources.

Strandberg-Larsen & Krasnik, 2009

Systematic review focusing on measurement of integrated healthcare delivery.

The review found that there are two distinct conceptual subcategories within the literature, where integrated healthcare delivery is seen as either:

a) an organizational structure that primarily follows economic imperatives (e.g. that unites a financing group with all providers—from hospitals, clinics, and physicians to home care and long-term care facilities to pharmacies) or

b) a way of organizing care delivery—by coordinating different activities to ensure harmonious functioning—ultimately to benefit the patients in terms of clinical outcome

The variety of concepts measured clearly reflect the conceptual diversity used within the field. There exists no consensus on which data sources best captures integrated health care delivery.

The identified studies can be categorized according to type of data source;

a) questionnaire survey data,

b) automated register data, or

c) mixed data sources.

Questionnaire surveys are, however, the most widely used data source.

NSW Ministry of Health 2018

This document provides the monitoring and evaluation framework for the NSW Integrated Care Strategy and it recognises the importance of considering the system persepctive


APPENDIX 2: REFERENCES Australian Consensus Framework for Ethical Collaboration in the Healthcare sector (2018). A consensus statement of shared values and ethical principles for collaboration and interaction among organisations in the healthcare sector.

Banfield M et al (2012). Co-ordination of care in Australian mental health policy. Australian Health Review, 2012, 36, 153–157

Bai, Y., Wells, R., & Hillemeier, M. M. (2009). Co-ordination between child welfare agencies and mental health service providers, children's service use, and outcomes. Child abuse & neglect, 33(6), 372-381.

Bronstein, L. R. (2003). A model for interdisciplinary collaboration. Social work, 48(3), 297-306.

Brophy L et al (2014). Impact of care co-ordination on Australia’s mental health service delivery system Australian Health Review, 2014, 38, 396–400

Brotherhood of St Laurence and the Australian New Zealand School of Government (2018). Making the Leap. Brotherhood of St Laurence and Australia and New Zealand School of Government.

Browne et al (2004). Conceptualizing and validating the Human Services Integration Measure. International Journal of Integrated Care - Vol.4

Care Quality Commission (2018). Beyond Barriers – How older people move between health and social care in England

Calciolari, S., Gonzalez-Ortiz, L., Goodwin, N., & Stein, V. (2016). The Project INTEGRATE Framework. EU Project INTEGRATE, EU Grant Agreement, 305821, 2016.

Curry C and Ham C (2010). Clinical and service integration- the route to improved outcomes. The Kings Fund.

Dalton H et al. (2018). Central Coast Integrated Care Program Formative Evaluation Report March 2018. Centre for Rural and Remote Health

Darlington, Y., Feeney, J. A., & Rixon, K. (2005). Interagency collaboration between child protection and mental health services: Practices, attitudes and barriers. Child abuse & neglect, 29(10), 1085-1098.

Dedrick, R. F., & Greenbaum, P. E. (2011). Multilevel confirmatory factor analysis of a scale measuring interagency collaboration of children’s mental health agencies. Journal of Emotional and Behavioral Disorders, 19(1), 27-40.

Durban et al (2006) Does Systems Integration Affect Continuity of Mental Health Care? Administration and Policy in Mental Health and Mental Health Services Research 33:705–717

El Ansari, W. (2011). When meanings blur, do differences matter? Initiatives for improving the quality and integration of care: conceptual matrix or measurement maze?. Journal of Integrated Care, 19(3), 5-21.

Fine M, et al (2000) Coordinated and integrated human service delivery models – final report. A report prepared for the NSW Cabinet Office and Premiers Department. Social Policy research Centre


Frey, B. B., Lohmeier, J. H., Lee, S. W., & Tollefson, N. (2006). Measuring collaboration among grant partners. American Journal of Evaluation, 27(3), 383-392.

Gagne, M-A., (2005). What is Collaborative Mental Health Care: An introduction to the Collaborative Mental Health Care Framework. Canadian Collaborative Mental Health Initiative, Available at: www.ccmhi.ca

Gardner, D. (January 31, 2005). "Ten Lessons in Collaboration". OJIN: The Online Journal of Issues in Nursing. Vol. 10 No.1, Manuscript 1.

Goodwin, N (2016 ). Understanding Integrated Care. International Journal of Integrated Care, 16(4): 6, pp. 1–4

Heenan, D., & Birrell, D. (2006). The integration of health and social care: the lessons from Northern Ireland. Social Policy & Administration, 40(1), 47-66.

Heflinger CA, (1996) Measuring service system co-ordination in managed mental health care for children and youth. Evaluation and Program Planning, Vol. 19, No. 2, pp. 155-163

Jenson, J. M., & Potter, C. C. (2003). The effects of cross-system collaboration on mental health and substance abuse problems of detained youth. Research on Social Work Practice, 13(5), 588-607.

Lewis, Richard & Rosen, Rebecca & Goodwin, Nick & Ifer Dixon, Jenn. (2009). Where Next for Integrated Care Organisations in the English NHS?. The Kings Fund/The Nuffield Trust.

Kania J & Kramer M (2011) Collective Impact. Stanford Social Innovation Review

Keast R (2011) Joined-Up Governance in Australia: How the Past Can Inform the Future. International Journal of Public Administration, 34:4, 221-231, DOI:10.1080/01900692.2010.549799

Keast R & Mandell M (2013). What is collaboration? Fact sheet 1. Australian Research Alliance for Children & Youth

Kodner D. (2009). All Together Now: A Conceptual Exploration of Integrated Care Healthcare Quarterly. Vo 13 Special Issue

Marek, L. I., Brock, D. J. P., & Savla, J. (2015). Evaluating collaboration for effectiveness: Conceptualization and measurement. American Journal of Evaluation, 36(1), 67-85.

Mental Health Commission of NSW. NSW Health Justice Partnership Community of Practice (2016) Health Justice Partnerships in New South Wales Position Paper

Morley, L., & Cashell, A. (2017). Collaboration in health care. Journal of medical imaging and radiation sciences, 48(2), 207-216.

National Mental Health Service Planning Framework (2019). Introduction to the NMHSPF: Population based planning for mental health

Noone, J. H., Marjolin, A., Skelton, L., Graham, K., Salignac, F., Powell, A. (2017). Collaboration Health Assessment Tool. Sydney: Centre for Social Impact

NSW Health (2018) Strategic Framework for Integrating Care

NSW Health (2018) Integrated Care Strategy Updated Monitoring & Evaluation Framework

NSW Health (2018) Review of Mental Health Commission of NSW - Report to Parliament 2018

NSW Government (2018) Integrated Service Response Operations Manual

http://www.ccmhi.ca/


Petri, L. (2010, April). Concept analysis of interdisciplinary collaboration. In Nursing forum (Vol. 45, No. 2, pp. 73-82). Malden, USA: Blackwell Publishing Inc.

Public Service Commission 2016. Collaboration review. NSW Government

Read, D. M., Dalton, H., Booth, A., Goodwin, N., Hendry, A., & Perkins, D. (2019). Using the Project INTEGRATE Framework in Practice in Central Coast, Australia. International Journal of Integrated Care, 19(2).

Raynor H (2009) The Heart of Integration. Journal of Integrated Care Volume 17 Issue 1

Schultz, E. M., Pineda, N., Lonhart, J., Davies, S. M., & McDonald, K. M. (2013). A systematic review of the care co-ordination measurement landscape. BMC health services research, 13(1), 119.

Shaw, S., Rosen, R., & Rumbold, B. (2011). What is integrated care. An overview of integrated care in the NHS. London: Nuffield Trust.

Smyth L (2009). Making integration work requires more than goodwill. Healthcare Quarterly. Vol 13 Special Issue

Statewide Primary Care Partnerships, Victoria. (2012) Victorian Service Co-ordination Practice Manual 2012 - A statewide primary care partnerships initiative

Statewide Primary Care Partnerships, Victoria. (2012) Continuous Improvement Framework 2012 - A statewide primary care partnerships initiative

Strandberg-Larsen M. (2011) Measuring integrated care. Danish medical bulletin

Strandberg-Larsen, M., & Krasnik, A. (2009). Measurement of integrated healthcare delivery: a systematic review of methods and future research directions. International journal of integrated care, 9(1).

Suter et al (2009) The Key Principles for successful health systems integration Healthcare Quarterly. Vol 13 Special Issue

Tasmanian Department of Premier and Cabinet. What is Collaboration? Tasmanian Government (accessed 26 June 2019)

Thomson, A. M., & Perry, J. L. (2006). Collaboration processes: Inside the black box. Public administration review, 66, 20-32.

Van Eyk, H., & Baum, F. (2002). Learning about interagency collaboration: trialling collaborative projects between hospitals and community health services. Health & social care in the community, 10(4), 262-269.

Walters, S. J., Stern, C., & Robertson-Malt, S. (2016). The measurement of collaboration within healthcare settings: a systematic review of measurement properties of instruments. JBI database of systematic reviews and implementation reports, 14(4), 138-197.

Widmark, C., Sandahl, C., Piuva, K., & Bergman, D. (2011). Barriers to collaboration between health care, social services and schools. International journal of integrated care, 11.

World Health Organisation (2016). Framework on integrated, people-centred health services: Report by the Secretariat

FINAL REPORT: MENTAL HEALTH COMMISSION OF NSW … › sites › default › ... · 2020-05-18 ·...

Documents

Transcript of FINAL REPORT: MENTAL HEALTH COMMISSION OF NSW … › sites › default › ... · 2020-05-18 ·...