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Collaboration 2 Recovery (C2R) Project Report
Fostering Partnerships for Whole-of-Life Wellbeing
29th June 2015
C2R
1
Acknowledgments
The Collaboration 2 Recovery (C2R) project was funded through Perth Central and
East Metropolitan Medicare Local (PCEEML)’s Partners in Recovery Innovation and
Collaboration grants. CoMHWA wishes to acknowledge PCEEML for sponsoring this
project.
We also wish to acknowledge also to our forum panellists: Kerry Hawkins, Carer
Consultant, Dr Andrew Davies from Perth Mobile GP Services; Paul Dessauer from
WA Substance Users Association; and Marina Korica, Fremantle Multicultural
Services. Finally, we appreciate the valuable contribution of the many consumers,
carers, families and service providers to this collaborative research to improve
partnership approaches for whole of life outcomes.
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Contents Executive Summary
1.Project Rationale
2.Methodology
3.Findings from the C2R Survey
3.1 Participant Profile & location
3.2 Profile of Services Referred to or Accessed
3.3 Capabilities of Services to Meet Needs & Support Wellbeing
3.4 Satisfaction with service collaboration to meet consumer needs
3.5 Enablers and Barriers to Inter-Sectoral Referral and Collaboration
3.6 System Navigation
3.7 Understandings of Recovery
4.Forum Findings
4.1 Shared Forum Learning- The Discussions
4.2 C2R Project- Evaluative Outcomes
5. Limitations
6. Contribution
7.References
8. Appendix A: C2R Forum Discussion Summary
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Executive Summary
Service integration and collaboration are vital to improving whole-of-life wellbeing
outcomes for people with multiple unmet needs, such as mental health, physical
health, homelessness and substance use challenges1. The National Framework for
Recovery also guides services to work together in ways that are person-centred,
socially inclusive and promote recovery2.
Based in Western Australia and delivered in 2014-15, the Collaboration 2 Recovery
(C2R) project utilised an action research methodology to build capabilities for regional,
multi-stakeholder collaboration focused on whole-of-life, person-centred, wellbeing
outcomes.
This Report captures the outcomes of C2R’s project. The process involved
consumers, families and service from across mental health, substance use and
primary care sectors contributing to a survey, followed by design and delivery of
participatory forums in two metropolitan regions.
The project and findings focused on identifying key barriers and enablers to person-
centred service referral and coordination partnerships for whole of life wellbeing,
together with strategies to improve collaborations for better outcomes. The project also
explored topics of recovery and system navigation.
The C2R surveys received strong response rates (167 participants, including 69
consumers, families and carers and 98 service providers). Most service providers (93)
provided mental health services, with a small number providing alcohol and drug,
primary health or other health & community services. Most participants were located
in the Perth metropolitan region.
Access to multiple services in order to address holistic needs is the norm, rather than
the exception, with many consumers accessing or being referred to a holistic range of
service types. There is potential to improve more referrals to a more holistic range of
options among many services.
1 Whiteford, H et al. 2014. 2 Commonwealth of Australia. 2013.
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Survey results indicate very low satisfaction with service capabilities to address needs
and support whole of life wellbeing, as a result of poor service design, poor service
availability and inconsistent quality. A significant majority- at least 2 out of every 3
consumers and service providers – felt that the capabilities of services to meet needs
and support whole of life wellbeing needed to be significantly improved and consumers
reported serious life impacts from poor service capability. The greatest factors raised
were rigid service criteria (accessibility), service availability gaps, and inconsistent
service quality. While collaboration is important to improving whole of life wellbeing
outcomes, the major concern for stakeholders was the need for a sufficient range of
service options to adequately meet needs and support wellbeing. While this is partly
about investing to address core service gaps, it also refers to a need to support quality,
and to redesign services towards more flexible, person-centred arrangements that can
address access barriers associated with siloed delivery.
Factors supporting effective collaboration were explored through both the survey and
subsequent forums. Survey respondents most commonly identified ease of referral,
person-centred collaboration and a supportive funding environment among various
factors, as key factors in effective collaboration. Ease of referral included knowledge
of suitable services and streamlined referral pathways. Person-centred collaboration
supports a shared agenda of the person’s needs and outcomes that encourages
flexible, cross-sectoral and team-oriented approaches, and a supportive funding
environment enables services to work more flexibly to meet people’s individualise
needs, with adequate capacity and time for collaboration. Forum discussions also
identified formal collaborative partnerships and programs, such as Partners in
Recovery, and capacity building for better collaboration, as two additional and
important strategies for enhancing collaboration.
C2R survey data indicates that service navigation is a major problem for addressing
multiple, unmet needs and is needed to improve ease of referral. Both consumers and
service providers were using professional networks and peer networks (‘word of
mouth’) as the most common means of finding services. They attribute more success
to ‘luck’ than through formal promotional methods such as flyers, pamphlets or stall
days. As this indicates a network-governed system, consumers not linked in with peers
or professional networks are likely to be at great disadvantage in locating a service.
Nearly all respondents (98-99%) felt there was a need for more navigation tools.
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The C2R survey investigated how recovery is understood by stakeholders, to
investigate the claim that the term recovery presents a barrier to integrating mental
health and drug and alcohol services. There was no clear preferred definition of
recovery, and most consumers and service providers selected multiple definitions as
meaningful to them. Only 10% of consumers and service users preferred not to use
the term recovery. As the majority of service provider respondents were mental health
services, this suggests that the recovery concept in the mental health sector is not
sufficiently uniform and rigid to present a barrier to substance user engagement.
Conversely, if service providers in the drug and alcohol sector have a clear preferred
definition of recovery focused on abstinence, then this may pose a barrier to
consumers who do not identify recovery with abstinence.
The two C2R Forums conducted post-survey were designed to build capacity for
collaboration through presenting interim findings, case study problem solving,
structured group discussion on collaboration networks and enablers, and sharing
knowledge of services with and between participants. The forums attracted 23
participants in Midland, and 22 participants in Perth Central.
The forum’s achieved outcomes were:
Increased understanding of enablers and barriers to collaboration for whole of
life outcomes, ( 80% Midland, 81% Central);
Increased understanding of enablers and barriers to collaboration for whole of
life outcomes (80% in Midland, 93% Central)
Increased capacity to improve partnerships for better whole-of-life outcomes
(70% Midland, 75% Central)
The unique contributions of the project were:
Extensive, local, empirical data on service collaboration and integration for
people with multiple, unmet needs, including both systemic issues and
‘frontline’ strategies;
Design of capacity building forums to improve collaborative practice in local
services, based on evidence of local needs, and
Integration of service provider and lived experience knowledge to support
collaborative practice.
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The C2R report is intended to provide a resource to stakeholders who are interested
in understanding the role of a person-centred collaborative ethos in supporting whole-
of-life outcomes, and using the shared expertise of stakeholders gathered over this
report for improving collaboration in practice. Stakeholder contributions span both the
grassroots level of day to day practice, through to systemic reform that reshapes
service access options to address needs and support wellbeing for people with
multiple, unmet needs.
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1. Project Rationale In this section, we outlined the rationale for consumer participation in research
generally, and for action research into the relationship between service collaboration,
service integration, people with multiple unmet needs, and whole-of-life wellbeing
outcomes.
Consumer participation in service and system change
CoMHWA is a not-for-profit systemic advocacy and is the peak body for mental health
consumers in Western Australia. CoMHWA listens, understands and acts upon the
voices of people with lived experience of mental health issues through independent
and consumer-led research, consultation and networks.
Consumer participation in research is important to shaping research objectives and
findings in ways that incorporate lived experience. This is particularly important
when understanding the effectiveness and impact of services and inter-service
relationships, because consumers are most affected by service quality and access
and thus have important lived experience knowledge to contribute.
Collaboration to address multiple unmet needs and address whole of life
wellbeing
C2R sought to identify ways to improve collaboration and service integration
practices to improve whole-of-life outcomes for people with multiple, unmet needs.
Collaboration and service integration have multiple definitions in literature. For the
purpose of this project, we defined collaboration as coordinated activities for a
shared purpose by multiple stakeholders. We defined service integration as formal,
sustained relationships that aim to offer a more holistic service experience. Service
integration is one mechanism through which collaboration is achieved between
services. Collaboration may also involve a broader range of stakeholders that
share a common goal, such as local councils, community groups, consumers and
family members.
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People with ‘multiple, unmet needs’ were the focus of the project. This term was
chosen as a broad and inclusive category that avoids sector-specific or diagnostic-
oriented language, in place of terms such as ‘comorbidity’, ‘complex needs’ or
‘pointy end’. Doing so focused the project away from consumers accessing specific
types of services, towards broader factors that lead to peoples’ needs not being
met.
As people with multiple and unmet needs often need to access support across
siloed sectors and services, collaboration and integrated approaches are of
particular importance if services are to support their needs in a way that is helpful
to the person. Collaboration, at an individual care level, involves the use of team
work to achieve more for people than individual services working in an isolated and
disconnected way (‘silos’). Siloed services have a narrower range of capabilities
and a narrow group of people who the service can benefit. People with multiple,
unmet needs are disadvantaged by these types of services, because they are less
likely to meet the criteria to be accepted into the service, and services are less
likely to have the breadth of experience and skills to assist in addressing more than
one need.
In addition to overcoming service ‘silos’, there is also strong recognition and
support by consumers to move beyond crisis-intervention to a more balanced
attention to crisis support combined with services for improving wellbeing. A service
system focused on crisis support provides short-term responses to serious issues,
but cannot provide the longer-term support that helps to rebuild the person’s
personal, financial and social resources to prevent further crisis and increase
wellbeing. People do not want to live their lives in ‘maintenance’- to just be
maintained in a state in which they have somewhat greater stability then they did
before services were involved, but still live in situations of hardship, isolation and
ill-health. Wellbeing, wellness, quality of life, recovery, and whole-of-life outcomes,
are similar concepts (used differently across sectors) for this bigger and better
vision of services. In this vision, services support people to thrive, not just survive,
through more holistic and sustained support for the range of changes they want in
their lives.
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2. Methodology Methodology
The C2R used an action research methodology. Action research is a type of applied
learning- learning for practical, real-world change. It is the application of formal,
systematic research methods to learning in practical settings in order to improve action
(Tripp, 2005). When learning in practical settings, learners move through repeating
cycles of acting, learning from acting, and incorporating what is learnt into better
actions. This cycle also happens in action research, and there may be several cycles
of improved understanding and changed action through the research process.
Action research methodology is useful for consumer-led research. This is firstly
because it focuses on social understanding and transforming actions for positive
change3. Secondly, the social and collective action focus of action research means
that the researcher and participant relationship is democratic, because the researcher
depends on the sharing of knowledge and action by participants for positive change4.
Method
The C2R project deployed a mixed-method of empirical quantitative and qualitative
inquiry, via stakeholder surveys and action forums.
Tripp (2005) describes a 7 step process utilised in action research projects (pp.15-16).
The C2R project largely follow this 7 step process for its method.
1. Establish research aim
C2R focused on a central research question:
How can collaboration and service integration be improved in order to better support
people with multiple, unmet needs to attain whole of life, wellbeing outcomes?
This was then translated into an action research question,
3 Winter & Munn-Gidding, 2001 in Koshy, Koshy & Waterman. 2011, p.10 4 Koshy, Koshy & Waterman. 2011.
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How can the C2R project enable those involved in collaboration and service integration
to improve these practices for better whole-of-life outcomes for people with unmet
needs?
2. Understand the situation
In order to understand how collaboration and service integration is being practiced
from both lived experience and service provider perspectives, two C2R surveys were
developed (a Consumer, Families & Carers survey and a Service Provider survey).
Carers, families and key supporters (e.g. friends, chosen family) were asked to
respond to the survey on behalf of the person they supported. This was in order to
enable a voice for consumers who may have been unable to directly participate on
account of their circumstances.
The surveys asked parallel questions, but tailored language to each stakeholder
group. The C2R surveys were distributed widely through mental health, alcohol and
drug sector and community sector networks, with a 9 week collection period (late
January to late April 2015). The results were analysed and interim results prepared for
presenting at the forums.
Initially, the survey had been planned as a minor part of the project. However, the very
high response rate to the C2R survey led to major, valuable findings that have
implications beyond the project in understanding collaborative enablers and barriers
(see C2R Post-Project Recommendations).
3. Establish an action research theory (a theory of how action can be
improved)
Based on the combined stakeholder feedback from both surveys, we designed
participatory forums in order to maximise forum opportunities to improve
collaborations. In line with the survey findings (to be discussed), forums were designed
to increase knowledge of service options, raise awareness of enablers and barriers,
grow collaborative networks, and practice person-centred collaboration. Feedback
from the first forum was also used to improve the design of the second forum in order
to target these learning outcomes.
4. Establish method to evidence the theory
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The forum used learning evaluation questions within forum feedback forms to measure
whether the forums had increased the following learning outcomes:
understanding of the role of collaboration in supporting whole-of-life wellbeing;
knowledge of enablers and barriers to collaboration; and
capacity for improved partnerships.
5. Act & gather evidence
Two Regional C2R Action forums were also widely advertised for an inclusive
audience, and were held on 24th March 2015 (Forum 1, Midland) and Friday 24th April
(Forum 2, West Perth). 23 participants attended the Midland forum (estimated 10
consumers & 1 carer attending) and the Perth Central forum attracted 22 participants
(estimated 7 consumers & 1 carer attending).
6. Present findings
Interim survey findings were presented to forum participants and Table notes from
small group discussions were gathered in order to further bring stakeholder knowledge
to the final report.
This final report brings together the action learning achieved over the course of the
project including:
Survey findings
Forum discussions
Forum learning outcomes
7. Present implications of findings for action research theory
This step was beyond scope of the project.
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3. Findings from the C2R Survey 3.1 Participant Profile and Location The C2R surveys were completed by 167 participants, including 69 consumers,
families and carers (Consumer Survey) and 98 service providers (Service Provider
Survey). The vast majority of services participating provided mental health services
(95.9%, n=93), with a minority from alcohol and other drug (AOD) (13.4%, n=13),
primary health care (4.4%, n=4) or other service providers (4.4%, n=4). See (Fig 1.1,
Service Respondent by Sector). Some service providers provided services in more
than one sector.
The majority of respondents to the consumer survey identified as consumer/service
users (n=55), followed by a proxy
response from a ‘key support’ (family
member, carer or other key supporter)
(n=21). 2 respondents identified as both
key supporters and consumers. Key
supporters were invited to complete the
survey on behalf of the person they
support in terms of that person’s needs
and experiences, in order to capture
proxy perspectives consumers who are unable to directly participate Consequently,
through this report where consumer responses are indicated, this includes responses
40
15
21
Fig 1.2 Consumer Survey Respondents
Consumer
Service User
Carer/FamilyMember
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Mental Health Drug & Alcohol Primary Health Other
Fig 1.1 Service Respondent Type by Sector
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from both consumers and key supporters completing the survey on someone’s behalf.
Where issues affecting key supporters were mentioned, these were noted and
incorporated into the qualitative discussion. Feedback from key supporters on this
survey approach is also included under Section 5, Report Limitations and
Contributions.
Consumers were asked about the geographical location of the main services
consumers accessed, while service providers were asked about the geographical
location of the services provided. Results were coded by ABS regional areas, metro-
wide, state wide or non-metropolitan (see Fig 1.3 Consumer and Service Respondents
by ABS Area). 92.5% of consumers accessed services in, and 93% of service
providers resided in, the metropolitan area. More respondents accessed or provided
services in the northern, central and eastern metropolitan regions compared to south-
west and south-east regions. This is likely due to uneven survey distribution, rather
than service availability or population spread, with significant numbers of North
Metropolitan Health catchment area service providers participating (covering East,
North and Central ABS regions).
0
5
10
15
20
25
30
35
South-West South-East East North Central Statewide Whole ofMetro
Non-Metro
%
Fig 1.3 Consumer and Service Provider Respondents by ABS Area
Service Provider Consumer
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3.2 Profile of Services Referred to or Accessed
Service providers were asked what services they frequently refer people to (n=89).
Consumers were asked what services they had referred to been referred to or
accessed in the last year, in order to capture self-referrals as well as referrals (n=63).
Multiple services could be selected.
The data was analysed for:
Most frequently referred services;
Comparison of frequency of referral by service type, with consumers’ access to
those service types in the past 12 months;
Breadth of service referrals (indicative of holistic referral approach);
Number of service types referred to or accessed by consumers (indicative of
need for collaborative practice)
There was some consistency between service and consumers in the types of services
most frequently referred to or accessed (Fig 2.1 Comparison of Referral Patterns-
Consumers and Services). These were: GPs, clinical mental health and community
mental health. Services in general reported referring to services far more frequently
than consumers reported they had been referred to or accessed. In order to better
visualise these differences between referral and access, a Needs ratio was developed
(% service type referred to by service, to % consumers reporting 12 month referral or
access to services). (Fig 2.2 Needs Ratio: Service Referral/Reported Consumer
Referral or Access). For example, a ratio of 5 indicates that services are 5 times more
likely to report frequently referring consumers to a type of service, than consumers are
reporting they have been referred to or accessed. A ratio of less than 1 indicates that
consumers report greater access or referral than service providers report referring to.
A high ratio might indicate differences between consumer perceptions of need and
service perceptions of need, or may indicate gaps in service availability. Highest ratios
were for emergency relief, housing and homelessness, legal services and alcohol and
drug services. Because the types of services with the highest ratio are frequently
reported to be under-resourced and difficult to access, we suggest the data is more
likely to reflect service gaps in these areas of support.
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0
1
2
3
4
5
6
7
8
9
10
Fig 2.2: Needs Ratio: Service Referral/Reported Consumer Referral or Access
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%
GP
Alcohol and Drug
Clinical Mental Health
Community Mental Health
Other Physical Health Care
Occupational Therapist
Peer Support Provider
Housing & Homelessness
Emergency Relief, Financial Assist
Advocacy
Legal
Other
Fig 2.1 Comparison of Referral Patterns- Consumers & Service Providers
Consumer referred to or accessed (12 months) Service Providers Frequently Referred to
16
The majority (57.7%) of services frequently referred to a breadth of service types, with
at least 5 or more service types referred to (Figure 2.3 Number of Services Types that
Services Frequently Refer to). The majority of services are therefore reporting a
holistic referral approach. 21.6% had a narrower referral process, with referrals to 0,
1 or 2 service types. Other services that respondents indicated they referred to were
family, carer and domestic violence services, community groups and facilities, HACC,
education and employment support. Other services consumers identified being
referred to or accessing, which were not captured by the service types, were informal
peer supports, HACC and NDIS.
59.1% of consumers were referred to or accessed at least 3 services in the past year
(Figure 2.4 Number of Service Types Consumers were Referred to or Accessed in the
Past Year). 22.9% used 5 or more service types and 6 consumers (9.8%) had been
21.60%
21.60%
10.20%
47.70%
Fig 2.3 Number of Service Types that Services Frequently Refer People to
2 or less 3 or 4 5 or 6 7 or more
40.90%
36%
13.10%
9.80%
Fig 2.4 Number of Service Types Consumers were Referred to or Accessed in the Past Year
2 or less 3 or 4 5 or 6 7 or more
17
referred to or accessed at least 7 services in the past 12 months. The total number of
services accessed may also be somewhat higher, as people may see more than one
provider within a service type (e.g. access several clinical mental health
professionals). This is significant because the more service providers involved in
supporting the person, the greater the risk that problems may arise through lack of
coordination, collaboration or integration in services. Consumers accessing a high
number of services that are not delivered in an integrated way can also experience
burdens from accessing multiple, discrete services, such as travel and phone costs,
administrative aspects (e.g. forms, evaluations), repeating and relaying information,
and the time and effort of trying to self-coordinate services involved.
The data set on services referred to or accessed tentatively suggests gaps in the
availability of crisis (emergency relief), housing, alcohol and other drug, legal and
advocacy services based on referral/uptake ratios. The data also suggests that there
is a strong need for service collaboration and integration, because a significant
proportion of consumers are accessing multiple services. A slight majority services are
referring across a range of service types. This suggests fairly broad awareness of the
need for holistic, whole-of-life approaches to support through a range of referral
options, while there is still potential for improvement among many service providers.
3.3 Capabilities of Services to Meet Needs & Support Wellbeing
Consumers were asked the extent to which services were meeting their needs (n=59).
They were also asked the extent to which services were supporting whole-of-life
wellbeing, not just keeping them out of crisis (n=58). This reflects that where services
are meeting basic needs, they may not necessarily be supporting people to make any
positive and significant changes that are important to their quality of life and wellbeing.
Services were asked to provide their views on their confidence that their referral
options (i.e other services worked with, not their own services) were able to meet
needs (n=89) and able to support whole-of-life wellbeing (n=88).
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Figure 3.1. Service Capabilities to Meet Needs
The majority of stakeholders did not feel satisfied that people’s needs were being met (Fig 3.1 Service Capabilities to Meet Needs). 69.7% of service providers and 76.4% of consumers were either neutral, dissatisfied, or very dissatisfied with service capabilities to meet people/s needs. The majority of stakeholders also felt that services were not effective at supporting support whole of life wellbeing. 62.1% of consumers, and 77.2% of providers, felt that services never, or only sometimes, supported whole of life wellbeing. Impact of Low Service Capability on People’s Lives While both consumers and services commented on reasons for poor service capability, consumers also commented on the impact it was having on their lives. This different contribution of ideas supports the importance of lived experience voices if
0
10
20
30
40
50
60
70
80
Never Sometimes Mostly Always
Fig 3.2 Service capabilities to support whole of life wellbeing
Consumers Service Providers
19
policy makers and services are to grasp the real-life impacts (positive or negative) of service design and decision-making. Poor service capabilities were having diverse but serious impacts on people’s lives (Fig 3.3. Adverse Life Impacts of Poor Service Capabilities to Meet Needs & Support Wellbeing). Consumers reported unstable or unsuitable housing and homelessness, traumatisation and harm to mental health; and loss of work or prolonged unemployment.
Fig 3.3 Adverse Life Impacts of Poor Service Capabilities to Meet Needs & Support Wellbeing
Prolonged unemployment(4)
Significant mental health impact (4)
Stress
Trauma or re-traumatisation, including intergenerational trauma (4)
Poor quality of life/wellbeing impact (3)
Discrimination at work and loss of job
Death from medical neglect
Trying to cope alone
Accessing services with no trust they can meet need
Overmedication
Unsuitable housing
Prolonged homelessness
Waste of time
Financial cost to the person
Unmet Needs and Poor Service Capability 23 consumers and 12 service providers provided comments on the topic of service
capability and unmet needs. The majority of respondents provided reasons for low
ratings, or cited reasons for poor service capability. The most cited reasons for poor
service capability to meet needs were similar across service providers and consumers
(Table 1.1 Reasons for Poor Service Capability to Meet Needs). The difficulty
assigning comments to inter-related issues did not result in a robust coding. However,
the categories of issues identified were drawn literally from key words and phrases
and so give a good indication of the major, broad concerns of respondents. Service
gaps or lack of options arose when a service was not available, either because of
geographic location or because of the nature of the person’s needs. For example, one
participant identified that they were unable to access services when they needed them
because they were required to be in crisis, although they wanted to access services
to prevent impending crisis. Both services and consumers reported a ‘hit and miss’
20
experience of services that pointed to inconsistent quality standards. Some consumers
reported mixed experiences within the same service due to differences in staff skill or
attitude. Services were seen as having highly restrictive (‘exclusion rather than
inclusion’ criteria, guidelines and rules), and not rationally organised, leading to refusal
of services to people. Related to this inconsistency, people had mixed experiences of
attitudes, with some staff being rude and disrespectful. Inflexibility both affected
access to the service and the degree to which services were able to accommodate
and support individual needs. Consumers were more likely to raise poor training,
particularly mental health and trauma informed care competencies. Underfunding or
lack of funding for services were identified as an issue for whether services had
capacity to meet needs. Lack of collaboration and communication was mentioned by
several respondents.
Table 1.1 Reasons for Poor Service Capability to Meet Needs
# Consumer Comments
# Service
Comments
Service Gaps or Lack of Options 9 6
Inconsistency of quality between services, or between staff within services
6 6
Control and inflexibility of services (rules, conditions, such as eligibility, including funder requirements)
6 4
Poor competency for care, e.g. mental health care, trauma-informed care, or physical health care
9 3
Poor attitudes and associated behaviour, including exclusion of families
6 2
Underfunding or no funding 0 3
Lack of service collaboration or communication 3 0
Poor Service Capability and Whole of Life Wellbeing Reasons for low service capability to support whole of life wellbeing, and not just keep
people out of crisis, were similar to reasons for low capability to meet needs. 19
consumers and 10 service providers provided comments.
Table 1.2 Reasons for Poor Service Capability to Support Whole of Life Wellbeing
# Consumer Comments
# Service
Comments
Poor competency for care, e.g. mental health care, trauma-informed care, or physical health care
6 0
21
Control and inflexibility of services (rules, conditions, such as eligibility)
5 1
Inconsistency of quality between services, or between staff within services
4 0
Service Gaps or Lack of Options 6 2
Lack of service collaboration or communication 1 1
Poor attitudes and associated behaviour, including exclusion of families
4 0
Service navigation issues 1 0
Consumer & Supporter Factors 3 4
Consumer and supporter factors were mentioned as factors in whether whole of life
wellbeing was supported. These factors were not identified as contributing to service
capabilities to meet needs. Consumer and supporter factors identified were different
for service providers and consumers. For consumers, 3 consumers discussed self-
help or self-responsibility as a factor in whether wellbeing was attained. For service
providers, 4 services mentioned that whether consumers are able to benefit from a
referral was partly dependent on the consumer’s assets. This included the consumer’s
self-advocacy skills, the presence of family supports to help them with the emotional
and practical support of connecting to a new service, and willingness to persevere with
the challenges of engaging with a new service. Service reliance on a consumer’s
capacity to benefit from referral is likely to result in low referral success for consumers
with lower self-advocacy and barriers to service engagement at a disadvantage.
Proactive follow up of referrals, and practical and emotional support by services
already involved with the person to assist the person to make connection with new
services, need to be offered to people by referrers to the extent they have capacity to
do so.
Summary Findings: The data set on service capability to meet needs and support
whole-of-life wellbeing clearly indicate that the majority of consumers and service
providers feel service capability needs to be significantly improved. Consumers report
serious life impacts as a result of poor service capability, from persistent
homelessness and chronic unemployment, to preventable deaths. Action needs to
consider solutions that include:
How to better improve, evidence and monitor service quality, with attention to
quality factors that affect capability to meet needs and support whole-of-life
outcomes.
How to better manage the workforce for mental health and trauma competency,
and for the key role that attitudinal competency has on care experiences;
22
How to improve service flexibility to deliver individual and person-centred support
approaches;
Funded-initiated and service-initiated strategies to move away from siloed, niche
service-client models (silos) towards more versatile services willing and able to
serve a broader, more inclusive client/consumer population;
Funder-responsiveness to identify and address inconsistencies in service
capacity and availability across regions and across diverse client/consumer
populations;
Improving communication, collaboration, and referral processes to better meet
needs and support outcomes;
Collaboration received less attention as a factor in service capabilities to meet people’s
needs and support wellbeing than service criteria (accessibility), service availability,
and quality. This does not eclipse the importance of collaboration (see next section).
It instead points to the importance of understanding collaboration as a way of working
that can improve- but not fundamentally solve- sectoral issues such as service
underfunding and problems in service design, mix and quality.
3.4 Satisfaction with service collaboration to meet consumer needs 8% of service providers and 23% of consumers and families were satisfied or very
satisfied that services were working together to meet their needs (Fig 3.4 Satisfaction
with services working together to support consumer needs). Conversely, collaboration
could be improved from the perspective of 77% of consumers and families, and 92%
of service providers.
21 consumers and 10 service providers provided comments to explain this rating.
Consistent with low satisfaction ratings, comments focused on the need for
improvements in collaboration. Inconsistency of collaborative working between
services, systemic issues and the need for better communication and follow up across
services, were raised several times. The need for collaboration to be focused on and
flexible to the person and also the key supporters involved was also raised. Several
consumers and family members commented that they have needed to drive
collaboration themselves to better meet their needs- personally finding services,
getting services to communicate with one another, and hopefully, moving beyond
communication to active collaboration for whole-of-life outcomes. This is similar to the
4 service providers’ who commented on reliance on the person’s own assets in the
23
referral process, and reinforces the learning that consumers and families are being
relied upon to address communication and collaboration shortfalls that should, ideally,
be prevented or remedied by the services involved.
3.5 Enablers and Barriers to Inter-Sectoral Referral and Collaboration
3.5.1 Factors Identified
Survey respondents were asked to identify factors supporting or hindering
collaboration. Service providers were asked to provide enablers and barriers to inter-
sectoral referral options (Enablers, n=63 and Barriers, n=69). Consumers and their
supporters were asked what helps, and what prevents, services working together
(Helps, n=52, Prevents, n=51).
Categories were developed inductively from qualitative responses, rather than using
an existing list of known barriers and enablers (Table 1.3 Factors Enabling Inter-
sectoral referral and collaboration). Categories developed in classifying service
provider responses were then checked for their fit with consumer data, but there was
a high degree of similarity across consumer and service provider comments. The
categories are relatively, but not perfectly robust, as some comments did not provide
sufficiently specific feedback (e.g. ‘communication’ as a factor) to be further classified.
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied
Fig 3.4 Satisfaction with services working together to support
consumer needs
Service Provider Consumer
24
The categories were able to be used across comments for both enablers & barriers
(i.e. where the presence of something is an enabler, it’s absence is a barrier).
Table 1.3 Factors Enabling Inter-Sectoral Referral and Collaboration
Ease of Referral Knowledge and understanding of who to refer to and the referral process, including criteria & eligibility.
Effective Communication General communication
Collaboration Culture Where cultural factors, such as professional attitudes and whole-of-organisational commitment are mentioned
Person-Centred Collaboration
Working to a shared agenda that is focused on the person and their family, their personal needs and goals
Ongoing collaborative relationships
Building and sustaining ongoing, working relationships between staff from across services that enable ‘warm referrals’ and frequent communication to support the person
Collaborative events Structured, inter-sectoral events that facilitate introductions to services and networking between services
Care coordination One person or agency (e.g. case manager, care coordinator) taking the lead in coordinating supports involved with the person
Service integration When services combine to offer shared services, such as through co-location, shared information systems, shared policies
Information Sharing and its methods/protocols
Where information sharing is listed, including policies & protocols, and feedback to the referrer
Trust and confidence Where trust or foundations for trust (e.g. openness, transparency, honesty) have been listed
Systemic (Funding) Factors:
Initially, this category was for all systemic factors however funding was the consistently raised factor, including under-funding leading to service waitlists, capacity issues, and policies around what is funded that create restrictive criteria.
Table 1.4, Ranked Factors in Inter-Sectoral Referral & Collaboration, highlights in
orange the 3 most frequently mentioned factors for consumers and services regarding
enablers & barriers to collaboration, together with an overall ranking. For services, the
three greatest enablers to inter-sectoral referrals were ease of referral, effective
communication, and a collaborative culture. For consumers, person-centred
collaboration, effective communication and ease of referral were the three most
mentioned factors in services working together. For services, the greatest barriers to
inter-sectoral referral were systemic (funding-related) barriers, difficulty of referral and
a non-collaborative culture. For consumers, the three greatest barriers to services
working together systemic factors (funding), a non-collaborative culture, and failure of
person-centred collaborative practice.
Table 1.4. Factors in Inter-Sectoral Referrals & Collaboration
25
Enabler Barrier Overall Ranking
(#Comments)
Ranking (# Comments) Service Consumer Service Consumer
Ease of Referral 1 (19) 3(11) 2 (30) 5 (7) 2 (67)
Effective communication
2 (17) 2 (17) 5 (10) 5 (8) 4 (52)
Collaboration Culture 3 (15) 7(2) 4 (11) 2 (23) 5 (51)
Person-centred collaborative practice
4 (14) 1 (29) 3 (8) 3 (16) 2 (67)
Building and sustaining ongoing working relationships
5 (11) 6(9) 5 (10) 4 (8) 6 (38)
Collaborative Events 6 (8) 8 (3) 7 (5) 8(1) 9 (17)
Care coordination 6 (8) 8(1) 8 (3) 9 (0) 11 (12)
Service integration 7 (6) 8 (1) 6 (6) 7 (3) 10 (16)
Information sharing 8 (5) 9 (6) 3(15) 8 (1) 7 (27)
Trust and confidence 9 (4) 9 (6) 4 (11) 6 (6) 8 (27)
Systemic (funding) factors
10 (4) 5 (10) 1 (41) 1 (32) 1(87)
When barriers & enablers were reconciled and an overall ranking was provided across
respondents, person-centred collaborative practice ranked as the greatest factor,
followed by ease of referral and, thirdly, systemic (funding) factors.
Interestingly, formal collaborative models and structures (the presence of a care
coordinator, formal service integration mechanisms, and sectoral collaboration events)
were the three least mentioned factors in inter-sectoral referral and collaboration.
3.5.2 Stakeholder Comments on Frequently Identified Factors
Stakeholder comments were reviewed against each of the factors, to further analyse
key enablers and barriers. Fig 1.1 Three Highest Factors Enabling Collaboration,
summarises the key issues stakeholders identified within the three most mentioned
collaboration factors.
26
Fig 3.5 Three Highest Factors Enabling Collaboration
Ease of referral is having a
good knowledge of services and services having referral processes that are easy,
rather than many hoops to jump through (such as ‘gatekeepers’ and paperwork).
Referrals can be easier when the referrer has an existing collaborative relationship
with one or more people in the service.
Working in person-centred and family inclusive collaboration was understood to
require a team communication and consultation approach (in which the person, their
family, and supporters are part of the team). This in turn required time and capacity,
which was identified as a key barrier to effective working. Supporters need to be
prepared to alter what their role was to suit the person, and to work in a way that
supports the person and their family member to be in the driver’s seat with respect to
the services supporting them. Person-centred collaboration was seen as providing a
shared agenda (the person’s needs and goals). It is therefore possible that person-
centred collaboration, as a principle of good support and a shared agenda, provides a
vehicle through which service differences and non-collaborative organisational factors
could be overcome to better serve people’s whole-of-life outcomes.
Supportive funding environments enable services to have the time and capacity to
collaborate. In such environments, services are designed to be inclusive to help
•Working knowledge of services
•Streamlined referral processEase of Referral
•Shared Agenda of Person-Centred Collaboration
•Wrap around, flexible service involvement
• Individual and families supported to be at the centre
Person-Centred Collaborative Practice
•Funding rewards and enables frontline
collaboration
•Stable funding (less competitive imperatives)
•More client group flexibility, less exclusion criteria
•Sufficient services (reduce waitlists)
• Interim supports on waitlist
•Enough time & capacity for working collaboratively
Supportive Funding Environment
27
someone who would benefit from them, rather than focused on a very narrow criteria
of who can be supported. They are also supported to work together. There are enough
services so that people can get support from people they are referred to quickly.
Services are not under so competitive that money or statistics override an ethical
obligation to help.
Funding was identified as the most significant barrier, but not a significant enabler.
This may suggest stakeholders do not have much firsthand experience of supportive
funding environments to draw on as examples of ‘what works’.
3.5.3 Other Factors
Other recurring issues were identified through similar comments across stakeholders
that are important to capture. For example, several non-government organisations and
clinical services described lack of confidence in the other’s type of service, suggesting
a NGO-Clinical divide is a referral barrier for some people. See Table 1.5 Collaborative
Practice- Other Enablers.
Table 1.5 Collaborative Practice- Other Enablers Effective communication Collaborative ethos (honesty, transparency,
openness, respect)
Willing to share/discuss ideas (not having to have all the answers)
Organisational collaborative ethos, commitment and leadership
Overcome barriers of silo mentality, competing for funding, narrow agendas and egos and politics
Organisation willing to collaborate despite risks
Staff diversity of background (knowledge, skills and experience drawn from across sectors)
Ongoing collaborative working relationships
Staff continuity
Face to face team work
Formal collaboration events Training for competency to work with people with multiple, unmet needs
Care coordination Nil
Service integration Nil
Information sharing methods/protocols
Good feedback and follow up to referrer
Information sharing to prevent duplicating information & stories
Trust and confidence NGOs & Clinicians fostering mutual trust
Services earning consumer trust
Findings
28
Survey respondents indicated there are many factors that play a role in how
effectively services work together.
The three most frequent factors that consumers and services identified were:
ease of referral;
person-centred collaborative practice; and
a supportive funding environment.
Ease of referral is having a good knowledge of services and services having referral
processes that are easy, rather than many hoops to jump through (such as
‘gatekeepers’ and paperwork). Referrals can be easier when the referrer has an
existing collaborative relationship with one or more people in the service.
Person-centred collaboration is when multiple supports work with a shared agenda-
the person’s preferences, needs and goals. Person-centred collaboration is the
opposite of support decisions that are focused on service interests and sector silos.
The person and those who support them (e.g. families) are supported and respected
to be at the centre. Services are flexible about what they do to fit the whole team
who are supporting the person, including family members. Collaboration makes more
sense when people are seen as people, with whole-of-life needs that are unlikely to
be met by one service alone.
Supportive funding environments enable services to have the time and capacity to
collaborate. In such environments, services are designed to be inclusive to help
someone who would benefit from them, rather than focused on a very narrow criteria
of who can be supported. They are also supported to work together. There are
enough services so that people can get support from people they are referred to
quickly. Services are not under so competitive that money or statistics override an
ethical obligation to help.
Funding was identified as the most significant barrier, but not a significant enabler.
This may suggest stakeholders do not have much firsthand experience of supportive
funding environments to draw on as examples of ‘what works’.
29
3.6 System Navigation
3.6.1 How People Find Services
The C2R survey asked consumers and services the extent to which they were able to
access services when they need them. Service access often depends on eligibility
criteria and wait times. However, knowing about services is the first step required for
someone to access services.
System navigation is the process of finding a needed support (service, support or
community resources). People want to be able to find supports quickly and easily
when they need them. Acquiring knowledge about supports quickly and easily is
important to all involved - service providers, consumers, key supporters (such as
families and carers) and advocates.
If you need support, but can’t find it, the result is prolonged distress and unmet need.
Ensuring system navigation works is therefore an essential component of supporting
people’s whole-of-life outcomes. One service provider made the urgency and
importance of system navigation very clear felt, stating:
“My perception is that there are a lot of people who are on the extreme
fringes of social and economic exclusion who are unable to engage services
in a meaningful way. As a sector (I say this as a provider myself) we have
let this group of people down, in a spectacular way because they are not
helped to navigate themselves around the complex myriad of services which
are out there.”
Survey respondents were asked how they (or the consumers they supported) found
out about the services they needed. Responses were similar across services providers
(n=68) and consumers (n=50). Both sets of responses indicated a very high reliance
on network relationships. Both service provider and consumer (peer/word of mouth)
networks, when consumers are navigating the system, were being significantly more
relied upon than the internet. ‘Luck’ ranked as a key factor more frequently than
promotional materials (e.g. brochures, newsletters and articles, community stalls, and
directories). And 10% of consumers responding indicated they were looking for
services they needed, but had not found them.
30
If people take the right steps multiple times, a positive result is likely to be perceived
as ‘luck’. Luck in finding services therefore becomes a factor in finding services when
the navigation system is unreliable. Our reliance on informal networks may also
contribute to ‘luck’. Informal networks are important sources of information but the
information is localised and variable in the quality and reliability of information, so that
repeated network communications (asking around) may be needed before finding the
right information.
It can be helpful to think about navigation systems in terms of how well they work:
A dysfunctional navigation system is one in which the process is fraught with
difficulty and efforts to find supports are frequently unsuccessful.
A problematic navigation system is one in which the process can be difficult or
take too long, but the majority of people will be able to find the right support to
link to.
A functioning navigation system is one in which the process is easy, timely and
results in successful linkage of people to their supports.
0
10
20
30
40
50
60
Service Referrals Peers & Word ofMouth
Internet Luck Promotions Not Found
Fig 3.6 5 Most Useful Navigation Methods (% used)
Services Consumers
31
The C2R results suggest that Perth has a dysfunctional navigation system for those
that navigate without network supports, and a problematic navigation system for
consumers and services who are well networked. In other words, reliance on networks
has become the dominant navigation method in the absence of formal, statewide,
comprehensive and well-known navigation platforms. Not everyone is equally
fortunate to have networks to support them. This is likely to create an inequity of
outcomes, where those who are most isolated from services and networks are least
able to find relevant supports.
The implications of these findings are that:
Firstly, as service provider and peer networks have a vital function in our current
system at this time, they need to be valued, grown and supported to be as
effective as they can at information sharing. For example, a service provider
offers more navigation benefits to a consumer when they have wide network
connections, and the time to locate options on the person’s behalf. Where
consumer networks and service networks are important sources of information,
opportunities to combine knowledge from these two types of networks could
improve the capabilities of both networks.
Formal, statewide, comprehensive and well-known navigation platforms need
to be developed to make it quick and easy to find knowledge of supports.This
is particularly critical for consumers who are not yet linked in with service or
consumer networks to benefit from them, such as those who are newly
accessing mental health services, those who have multiple unmet needs, and
those at risk of developing mental health issues.
Centralised and coordinated navigation platforms have data collection
capabilities that can evidence capacity and demand for services (e.g. waitlist
length, volume of referral and enquiries) through which to better understand
and respond to the service gaps explored earlier in this report.
3.6.2 Useful Tools
Survey respondents were asked which tools would be most useful for finding out
services (consumers, n=58, services n=82). More than one tool could be selected and
the majority of respondents indicated multiple tools would be helpful. Consistent with
this, only a small minority (1% of service providers and 2% of consumers) felt there
were enough tools to locate services. 1 in 5 service providers and 1 in 3 consumers
32
listed other tools. These widely varied, with several respondents commenting on the
need to avoid a one size fits all approach. These are summarised below, with tools
and quality aspects separated.
Figure 3.7 Useful Navigation Tools (% Agree)
The Quality Aspects were:
Online & offline options (for those without computer access or literacy) (5)
Info needs to be kept up to date (4)
It’s valuable to have a range of options (4)
Consolidate and/or link directories to the one place (2)
Tools link to each other (apps, websites hotlines)
Sufficient information (access, waiting times, hours available)
Information service to identify options, then contact the person
Table 1.6 Other Tools Information and referral services
Central referral & resource service/hub(4)
Live phone line Regions
Regional Hubs
Regional directories (all support services and networks)
0%
10%
20%
30%
40%
50%
60%
70%
80%
Service
Consumer
33
Services as Referrers
Support with transition, long time frames in which periodic follow up takes place to prevent people falling through the gaps (in, out, between services)(3)
Other navigation supports
Community Events/awareness stalls(3)
Information sessions(2)
Care plan
Word of mouth(2)
Peer support group
Networking sessions
Leaflets
Peer workers
The data set on system navigation identified that:
Consumers and services rely on peer and service networks to find services in
the absence of effective, centralised navigational services and resources. The
implications are that consumers who do not have these peer networks, or who
access a service that is not well networked, is at greater risk of ongoing, unmet
need.
Even with such networks, it is very challenging to find services and many
consumers and services count on ‘luck’.
Networks are an essential referral resource for consumers and services that
need to be supported. Centralised navigation services also need to be
improved.
People wanted more tools to be available, including mobile apps, websites,
directories, hotlines and information sessions. Information needs to be up to
date and useful so people can know whether they can access a service, how
to access, and how soon they can access.
3.7 Understandings of Recovery
Consumers and services were asked to indicate a definition of recovery most
meaningful to them. 91 service providers and 67 consumers responded to this
question. The purpose of this question was to gauge the degree of consistency in
understandings of recovery between stakeholders and whether there were dominant
understandings of recovery.
34
This is of significance to collaboration because it has been commented that the term
recovery is understood as abstinence in the substance use sectors, and abstinence is
a specific treatment goal that not all substance users share. Use of the term recovery
in mental health, which has a different meaning, can thus present a significant
language barrier to engaging with mental health services on the part of substance
users who do not want to practice abstinence.
In contrast to these claims, the vast majority of respondents used multiple definitions
of recovery that could be variously understood as a flexible orientation, or ambiguous
orientation, to recovery. 72 service providers (75%) found 3 or more definitions of
recovery most meaningful, and 42 consumers (60%) found 3 or more definitions most
meaningful (Figure 3.8 Number of Recovery Definitions Found Meaningful by Services
and Consumers). Only 10.4% (10) service providers and 8.7% (6) consumers used a
single definition.
While service providers were most likely to include ‘a meaningful life regardless of
symptoms’ among definitions used (80%), there were no clear majority definitions
preferred by consumers (Fig 3.9 Recovery Definitions Meaningful to Services and
Consumers). 3 definitions were used by a slight majority of consumers (ranging from
57% to 66%)). Cure and abstinence were used only by a minority of consumers and
service providers (less than 10%), and ‘meaningful life regardless of addiction’ was
used more often than ‘abstinence from substances of addiction’ by both consumers
and service providers.
0
5
10
15
20
25
1 2 3 4 5 6 7 8 9
Fig 3.8 Number of Recovery Definitions Found Meaningful by Services and Consumers
Consumers Services
35
Consumers were more likely to reject the term recovery than service providers (10.1%,
n=7 compared to 1.0%, n=1). They also gave more alternative definitions of recovery.
Alternative definitions were provided as alternatives too, but also in addition to, the
survey definitions used. Reasons for rejection of recovery were not always commented
on, however comments suggested feeling stigmatised- having their life process or
identity recognised differently from ordinary human beings. Alternative consumer
definitions of recovery included dimensions such as: self-direction, happiness,
purpose, wellness, integrating and valuing experiences, relationships and resources,
rebuilding life, independence, community participation, self-responsibility, life’s
journey, self-awareness and spiritual growth. Alternative service provider definitions
were less common, but included dimensions such as: relationships, resilience, a full
life through adequate supports, individualised approach, community support and
engagement.
While the data indicates there are more and less frequently used ideas in the recovery
dictionary, the majority of consumers and services are using multiple meanings,that
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Absence of symptoms
Abstinence from substances of addiction
A meaningful life regardless of symptoms
A life of social and economic participation
A meaningful life regardless of addiction
Cure
Management/ maintenance
Whole of life wellbeing
I reject the term recovery
Other
Fig 3.9 Recovery definitions meaningful to services and consumers
Consumer Service Provider
36
may either signify ambiguity about what counts as legitimate recovery, or flexible ideas
about what counts. An ambiguous orientation to recovery may be confusing for
consumers, particularly if different definitions are used across services involved in
care. On the other hand, a flexible orientation to recovery may facilitate a process of
ongoing conversations focused on exploring different ways of perceiving recovery, and
enabling consumers to self-define their recovery. In these scenarios, a legitimate
definition is one that is legitimate (make sense and is acceptable) from the consumer’s
personal perspective, or is rejected. This also suggests, firstly, that the language
divide, between mental health and drug and alcohol sectors, may be overstated, and
secondly, that attempts to find a mutually agreeable definition across sectors may be
at odds with the way the term recovery is used in practice by services and consumers.
Summary Findings
The C2R survey investigated how recovery is understood by stakeholders, to
investigate the claim that the term recovery presents a barrier to integrating mental
health and drug and alcohol services. There was no clear preferred definition of
recovery, and most consumers and service providers selected multiple definitions as
meaningful to them. Only 10% of consumers and service users preferred not to use
the term recovery. As the majority of service provider respondents were mental health
services, this suggests that the recovery concept in the mental health sector is not
sufficiently uniform and rigid to present a barrier to substance user engagement.
Conversely, if service providers in the drug and alcohol sector have a clear preferred
definition of recovery focused on abstinence, then this may pose a barrier to
consumers who do not identify recovery with abstinence.
4. Findings from the C2R Forums 4.1 Forum Purpose The C2R forums were intended to build capacity for person-centred collaboration for
whole-of-life wellbeing, through:
Distributing information about a holistic range of services, and key literature in
collaboration (resource packs);
37
Presenting preliminary findings from the C2R report, which emphasise the need
to improve collaboration and wellbeing in services, and the critical roles of
system navigation ‘know-how’ and a person-centred approach;
Developing new network relationships between participants;
Share participant knowledge of collaborative practice approaches
Share participant knowledge of local service and support options
The forum encouraged open and inclusive attendance of consumers, families and
supporters, and service providers (including mental health, substance use, cross-
sectoral, clinical and GP services). Participant payments were provided to address
potential barriers to consumer and family/supporter participation on the day.
Panel members were selected who had significant experience in working
collaboratively to support people with multiple, unmet needs. The role of the panel was
to provide a point of established and reflective expertise to support discussion and
dialogue across participants.
Participants worked collaboratively on case studies of people who had multiple, unmet
needs. This included joint discussion of enablers and barriers in collaboration, service
and support options, and how to support person-centred, whole-of-life outcomes.
4.2 Shared Forum Learning- The Discussions
Overview
A summary of forum table discussions (collated and themed) is separately provided in
order to share learnings from the forum with participants and others interested
(Appendix A. C2R Forum Discussion Summary)
These were themed into:
I. Addressing barriers to collaboration for whole-of-life wellbeing outcomes;
II. Thinking holistically about supports for whole-of -life wellbeing;
III. Suggested systemic enablers to collaboration;
IV. Good practice in person-centred collaboration at the ‘grassroots’- i.e. things to
think about when directly involved in providing or receiving support in
partnership
38
The Midland forum attracted 23 participants and the Perth Central forum attracted 22
participants. Forum attendees were not required to identify at forum registration,
however estimates were 10 consumers and 1 carer at Midland forum, and 7
consumers and 1 carer at Perth Central. The strong common ground between
participants was around recognition that collaborative partnerships, rather than silos
or single expert approaches, are essential when the person’s holistic needs are
understood and when their unique identity is appreciated. This is because seeing the
person as a person (not a problem, but with unaddressed needs) enables those
involved to:
Recognise the strengths and relationships of the person as essential resources
for supporting wellbeing, and thus part of collaboration;
Recognise the person’s rights to choice and control around who supports them,
and how;
Recognise a range of circumstances in which needs and aspirations arise-
such as housing, work, and health; and
Recognise the need for cross-cultural collaboration as central to working with
people from culturally and linguistically diverse backgrounds, their relationships
and circumstances.
Suggested systemic enablers to collaboration (III) that were identified were sub-
grouped into: a common culture/shared understandings; service design; capacity
building for collaboration; and formal partnerships
Ease of Referral & Service Funding Issues: Addressing some of the service
design issues, such as rigid criteria, and the degree of frontline assistance that
is able to be offered in order to provide a ‘no wrong door’ approach. The general
theme across these was around recognising and supporting the potential for
services to be done differently- to foster closer connectedness with informal
supports and communities, and be more welcoming and flexible points of entry
to collaborative networks of support
Shared Culture: Shared cultures, including shared language and principles for
collaboration. This implies mechanisms for sharing and co-creating cultural
ideas and beliefs across services, with a focus on what people and their families
find helpful
Formalising Collaboration: Formal partnerships, such as the Partners in
Recovery model and other initiatives that aim for either service integration and
39
sustained collaborations at inter-agency level, with a focus on how partnerships
can improve outcomes for people, rather than working in silos alone
Understanding and practicing grassroots collaboration: Recognition that
person-centred collaboration at the grassroots (with people accessing
supports, right now, by those involved) is at least as essential as formal
collaboration approaches and efforts to reform systems. Ultimately, the topic of
person-centred collaboration is about people working at a personal level to
support people in their wellbeing. These ideas were focused around how to be
a good supporter across people’s unique needs, and how to engage and
participate in team work relationships and actions to be of most benefit.
Comparison of Survey & Forum Findings
Forum themes on key collaboration enablers that were developed inductively when
collating the findings were not identical, but similar, to the themes identified in the
survey. The forum results broadly aligned with the survey responses. The forum
differed from the survey in that formal collaborative partnerships and capacity building
projects & ideas were also identified as a key enablers for collaboration.
C2R Collaboration Factors Identified
Survey Forum
Ease of Referral Service Funding Issues
Ease of Referral & Service Funding Issues
Person-Centred Collaboration Person-Centred Collaboration
Collaborative Culture
Ongoing Collaborative Working Relationships
- Formal Collaborative Partnerships
- Capacity Building for Collaboration
4.2 C2R Project- Evaluation Outcomes Overall satisfaction rates for the forums were high (90%Midland, 93% Central). Each
forum measured self-reported learning and participation outcomes (Fig 4.1 Forum
Participant Learning Outcomes). Learning Outcome 2 was an increase in
understanding of enablers and barriers to collaboration for whole of life outcomes, with
40
80% of Midland participants and 81% at the Central forum agreeing or strongly
agreeing this learning outcome had been met. Learning Outcome 3 was an increase
in understanding of the role of collaboration in supporting whole of life outcomes, of
which 80% in Midland and 93% in Central agreed or strongly agreed they had
increased understanding in this area. Participants rated learning outcome 1, capacity
for improved partnerships, lower than the other learning outcomes for the forums (70-
75% reported increase capacity). This is likely to reflect the more sustained activities
required for capacity building outcomes, such as in nurturing relationships for ongoing
partnerships, and direct, ongoing, practical experience and skills development in
partnership practice.
Outcomes were somewhat higher for the Central forum. This is likely to be a result of
several improvements to the forum day to provide a greater shared focus and
discussion time. The central forum included an introductory presentation sharing ideas
on successful collaboration. The panel-based discussion of case studies were briefer,
enabling more time for small and combined group discussions, and the panel also had
a more engaged role as facilitators of the small group discussions.
5. Project Limitations The survey data was initially planned as a scoping survey of issues for forum design,
and become an unexpected, major outcome on account of the significant number of
people who contributed to the survey. Due to the initial purpose of the survey as a
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%
Learning Outcome 3: Understanding role ofcollaboration in outcomes
Learning Outcome 2: Understanding collaborationenablers and barriers
Learning Outcome 1: Capacity for improvedpartnerships
Opportunity to contribute ideas to improvepartnerships
Forum Participant Learning Outcomes
Central Midland
41
scoping exercise, data was subject to basic reporting of findings, without testing for
statistical significance or validation of qualitative coding. Significant survey uptake may
indicate that stakeholders have an interest in contributing to best practice and change
in the topics, which may be supported by formal research.
Several carers were dissatisfied with the survey design process for only enabling
carers and families to contribute as proxies. CoMHWA will give further consideration
to survey design methods that can resolve this tension between the value of proxy
options for consumers, the importance of hearing from carers on carer needs and
experiences, and the need for ease of survey completion by carers. Additionally, the
interesting findings of this report may encourage further enquiry into how collaboration
for whole-of-life outcomes can be achieved for individuals, families and carers.
While the survey attracted a significant number of responses, it is important to
recognise that the survey was heavily weighted towards metropolitan regions and
mental health sector respondents despite broad targeting to inter-sectoral networks.
A broader regional and inter-sectoral contribution is important to building a more
comprehensive picture of what would be people with multiple, unmet needs and their
key supports would find helpful to their wellbeing outcomes.
6. Project Contribution
The C2R project made several unique contributions to understanding and practicing
collaboration. It provided extensive, local, empirical data on service collaboration and
integration for people with multiple, unmet needs. This has provided an essential
evidence base that lends support to many issues raised anecdotally by stakeholders.
It has progressed the integration of service provider and lived experience knowledge
in the topics of focus (collaboration, service integration, wellbeing).
Through the action research methodology, it has delivered forums that have used
contemporary and local evidence of stakeholder priorities and needs, in order to build
capacity for person-centred collaboration within Perth and Midland regions.
In contributing to understanding of local and contemporary issues and needs for
person-centred collaboration, CoMHWA is committed to working collaboratively with
stakeholders who share the passion for building person-centred collaboration into
systems, networks and services. We hope this project is able to sustain its impact as
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a learning resource for shared understanding of the importance of a person-centred
collaboration and for embedding the ethos further in practice, service design and
commissioning. We also hope that the significant stakeholder feedback from this
report on service navigation, accessibility and availability, is heard and used to
improve outcomes for people across sectors with multiple, unmet needs.
References Commonwealth of Australia. 2013. A national framework for recovery-oriented mental
health services: Policy and theory. Canberra: Commonwealth of Australia.
http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-n-
recovfra
Koshy, E., V. Koshy & H. Waterman. 2011. Action Research in Healthcare. Los
Angeles, Calif.: SAGE.
Tripp, D. 2005. Action Research: A Methodological Introduction.
http://www.revistas.usp.br/ep/article/download/27989/29771
Whiteford, H et al. 2014. System-level intersectoral linkages between the mental
health and non-clinical support sectors: A qualitative systematic review. Aust N Z J
Psychiatry. 48(10):895-906.
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Appendix A. C2R Forum Table Discussion Summary
1. Barriers to supporting whole-of-life wellbeing
Service Barriers:
o Eligibility lottery- postcode, age restriction (adolescent versus youth) o Lack of capability to work across mental health and substance use issues o Services not working with the person’s whole needs because working in silos
and not assertively making linkages (e.g. homelessness issues) o ED resources are geared to the wrong shift (i.e. least staffing & allied support
after hours when most needed) o Lack of afterhours supports in general (phone lines don’t work for everyone) o Services are not helping people from the CALD community effectively (see
‘thinking holistically below’) o Services need to suit the person (their needs, values) o Negative experiences from services challenge further engagement with other
services, e.g. inappropriate care settings (emergency departments, involuntary treatments), inappropriate treatment approaches (e.g. abstinence rather than reduction or harm minimisation)
o Restrictions on crisis, transitional and supported accommodation for people who are using substances
Situational Barriers:
o Person’s contactability (e.g. when homeless) o Where there is limited family, friends and community supports for practical
and emotional support in linking in with services
Other Barriers:
o Stigma associated with mental health and substance use issues
2. Thinking holistically about supports for whole of life wellbeing
Safety:
o Intensive support for and with the person to reduce risk of suicide e.g. safety planning
Holistic Approach to Crisis/Stability:
o The need to work responsively and proactively to help people move from crisis to stability, e.g. stable accommodation, help with early episode psychosis, rehabilitation
Multi-Support Approach:
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o Engaging a range of supports for person-centred, whole of life needs (e.g. housing, mental health and alcohol and other drugs, mentoring, GP, family and friends)
o Include supports to identify, focus on and pursue strengths and aspirations (not just services that aim to reduce issues/address needs, such as arts mentor, community clubs, useful employment supports)
Cross-Cultural Collaboration
o Thinking holistically around supports for people from CALD backgrounds, and changing mentality from ‘doing to’, to learning from the person and their community supports in how to assist
3. Supporting collaboration at inter-sectoral, regional and systemic level
Shared Cultures of Collaboration:
o Building a culture of early intervention o Shared language, terms including de-medicalising/destimatising o Shared understanding of whole-of-life wellbeing and strengths-based
approaches o Must be person-centred collaboration (see ‘Person-Centred Collaboration at
the Grassroots’, below)
Ease of Referral & service Funding Issues
o Services enable everyone to help responsively: no wrong door, no rejection by services, limit the ‘exclusion’ criteria to be more flexible to respond to who presents at services
o Referral forms- less problem-oriented & deficit based, need to identify information on person as person, their roles, strengths & goals
o Informal community assets need supporting and resourcing (weekends, local, non or minimally funded; centred around activity, mutuality , engagement and inclusion- not service), e.g. day centres, community centres, rec facilities, volunteer orgs, interest groups
o Identify models that are working well o Mainstream presence of supporters in services (families, peers) to facilitate
empowerment, choice and control o Bring collaborators to non-collaborating spaces (e.g. social workers and peer
workers in emergency departments) o Inreach supports could assist accommodation and clinical providers to be
more flexible with who can access (e.g. alcohol and drug workers inreaching to mental health accommodation)
o Stronger trauma informed care o Whole of life assessment tools (housing, mental health, employment, alcohol,
substance use etc.)
Capacity Building for Collaboration
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o Building capacity for collaboration- breaking down silos through shared practices, methodologies, skills, experiences
o Build capacity for greater GP collaboration and early intervention/intensive support, e.g. are social workers a more achievable option than nurse practitioners in enhancing primary and holistic health care?
o Clinician training and accountability, especially around suicide and other harms risks
o Community development to bring stronger connectedness across services o Build peer support options- directories of peer workers and groups o Training across diversity (e.g. culturally appropriate training) o Consumer and carer organisational leadership in collaboration is critical to
keeping collaboration consumer & family centred o Honesty around resource inefficiencies- overhead relative to on the ground
supports; over-resourcing & under-resourcing between groups; entry of some for-profit companies a concern for person-centred care
o Relationship building networks, such as the Change Action Team o Gatekeeper training in community-based approaches, links to community
assets (services, resources, networks). Focus on GP, police, ambulance, ED staff both current staff and future staff (students)
o Self-advocacy resources, e.g. choosing the right GP o Build access and capabilities for translators o Formal Partnerships build capacity (see below) o Person-centred collaboration (see below) increases capacity for collaboration-
through built network relationships and shared knowledge and skills for further person-centred collaboration
Formal Partnerships:
o Strategic as well as grassroots- mapping local networks of potential and existing partnerships , and what they could collectively achieve, and ensure partnership groups work towards and measure shared outcomes- mutually reinforcing activities. Person-centred collaboration mirrored upwards (co-production approach).
o MOUs can be barriers (language, set and forget due to lack of time to meet and discuss, funding requirements, status and other motives can step in)
o Partners in Recovery – deliberate and resourced staffing to coordinate and connect supports across silos at individual and organisational level. Note: lead agency needs to be able to appreciate whole-of-life wellbeing and bird’s eye views of community support options. Narrow views of needs remove need for a range of collaborative partnerships.
o Need to better measure the difference made, and what’s effective, in working together rather than the silo effect
o Service Integration- with a focus on improved access and collaboration (e.g. co-location)
4. Person-Centred Collaboration at the Grassroots
Principles of support:
o Being flexible to the person- partnering in how harm will be addressed (e.g. abstinence versus harm reduction). Identifying that some forms of harm are also sources of strength- i.e. the person’s way of coping- and thus the option
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for reducing harm is more realistic when alternative strategies are developed, and stability in life (esp. housing) is secured
o Focus on the person and their life goals, strengths, aspirations. Goal is what is important to the person
o Instil Hope o Walking alongside the person o Dignity of risk- tensions with risk management o Reducing professional distance to have a personal connection with the
person without breaching boundaries unsafely with the person, requires managing the limits of service design, as well as conduct (e.g. availability & contactability)
o Ensure time to build relationship safety and trust
Building partnerships with supporters:
o Support existing, informal supporters o Clear sense of shared purpose o Joint meeting o Real options, not just numbers, that is introduced as a possible new member
of the team- not handed to the person as a separate additional service (warm referrals and services making links with the person)
o Care Coordination/Support Facilitator Approach: Facilitator/lead to assist potential partners to connect formally and
informally Action Plan developed based on person’s goals and needs, including
timelines & accountability Team-based plans (consumer is the leader) Person decides roles, meeting spaces- control & empowerment Key person chosen by the person being supported, such as PiR
facilitator or advocate , who facilitates communication, coordination and collaboration between people involved
Mapping together can be helpful (resource options & support options to match goals)
Person-Centred Collaboration & Cross-Cultural Collaboration– Things to Consider for People from CALD Communities
o Transforming culture of service from ‘doing to’, to mutual cultural learning and respect
o It’s helpful for supporters to understand of refugee & asylum seeker situations in terms of both practical, emotional and potential trauma issues, such as separation from family;
o Practical financial supports associated with settlement and visas may be a priority, such as leasing properties, advocacy with Centrelink
o Customs of engaging with services may differ from the dominant culture (e.g. beliefs about complaints, service choice)
o Experiences of racism o Understanding of cultural understandings of ‘mental health’, language, the
approach to supporting good mental health and extent of stigma o Culturally appropriate assessments, avoiding duplication of assessments
wherever possible
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o Not assuming that a formal service is the best starting point (may be a community leader, or friend, with whom relationships of trust, support and understanding exist)
o Not assuming that a specific sector is the best starting point (person may benefit from a worker from another sector from the same culture and/or who has proficiency in the person’s primary language).