Title: Use of the new paradigm of healthcare ecosystem research in mental health planning Luis Salvador Carulla, Carlos Garcia-alonso, Jose albero Salinas, Nerea Almeda and Mary Anne Furst. CMHR, ANU, Loyola University INTRODUCTION: Health Ecosystems Research (HER) is a new discipline in implementation sciences that incorporates systems dynamics, context analysis, health economics and knowledge discovery from data. HER is particularly relevant for the analysis of integrated care. METHOD: A collaborative strategy based on systems research has been implemented to regional mental health planning based on context analysis. The organisational learning strategy included: i) the development of the conceptual model, ii) atlases of regional Mental Health Care, iii) integrated resource utilisation analysis applying new units following the recommendations made by the PECUNIA group(*), v) geospatial analysis of administrative prevalence, vi) financing of mental health care, vii) cost of illness of sentinel conditions, viii) modelling of efficiency and organisational improvement. RESULTS: All the blocks of this strategy have been used for policy including the regional mental health strategic plans in Catalonia and the Basque Country (Spain). From a summative perspective the main factors related to the success of the strategy have been 1) the agreement on the framework and drivers included a common taxonomy, 2) policy of full transparency by the public agency,3) the continuity of the planning team, 4) the multidisciplinary  and flexibility of the reference network, 5) the development of a general framework for the collaboration, 6) the use of bidirectional multiple sources of funding, 7) the trust building process for effective knowledge transfer and bridging, 8) use of policy opportunities to increase the general knowledge base. Major challenges for implementation have been: 1) the need to accommodate the global strategy to specific short-time policy demands, 2) the lack of continuity of research funding and research teams, 3) the difficulty of information generated for practical use by decision makers and stakeholders without expert guidance, 4) the political cycles, 5) structural and administrative constraints in the Spanish public and research systems. This experience is being applied to local planning and expert-guided evidence informed policy in Australia DISCUSSION: The healthcare ecosystems and context analysis framework is key for evidence-informed regional planning. The Spanish case highlights the importance of an integrated health ecosystems approach for use of health economics data in the real world.  (*) The PECUNIA project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 779292.

Title: Implementation of a comprehensive systems of integrated mental health service delivery in urban areas. Lessons learned from the Inner Sydney Urban Partnership for Health and Well-Being Introduction Notwithstanding the high priority given to the development of systems of integrated mental healthcare in Australia in National and State Policy, little has been done to guide how this should be done, for whom, by whom and to what end. This presentation surveys the challenges involved based on the experience gained by a dedicated group of providers, funders, cares and consumers in NSW through the establishment of an Inner Sydney Urban Partnership for Health and Well-being. This initiative is referenced to other initiatives in Australia, albeit those that have been systematically developed are relatively rare or seldom reported. Learnings are shared and a framework for achieving more durable success in Australian settings is presented. Method The presentation is based on an a series of symposia held between 2015-2016, an implementation process undertaken by Synergia between 2016-2017 and a follow-up consultative process undertaken by the author in 2018 for St Vincent’s Health Network, Sydney. Results From its inception there was considerable enthusiasm for a broad group of providers, funders, consumers and carer organisations working together. In Sydney by 2017 22 NGOs, the Central Eastern Suburbs PHN, Family and Community Services, Consumer and Carer Organisation’s had become involved in the collaboration, early draft of protocols and bids for funding made. In addition the services had been surveyed by Professor Luis Salvador-Carulla and his team at SYDNEY University, using the Mental Health Atlas methodology which he had developed. The basis for a robust integrated care network seemed to have been laid. However the loss of key personnel, restructuring within the lead organisation and a lack of shared financial commitment led to an abrupt loss of momentum in the implementation process. The 2018 survey showed however that there were other less obvious factors involved that are referred to under “lessons learned” that may have been equally critical in the outcome at the time. Nevertheless, continuing interest in re-establishing the Partnership was still evident in the 2018 consultation and in fact St Vincent’s Mental Health Service has included the initiative in its Strategic Plan and is supporting research to underpin its re-development. Conclusions • Integrated Mental Health care is hugely challenging but is required by both Federal and State policy. • Stakeholder know that consumers benefit when services work together to focus on their needs and that things can go seriously wrong when they don’t. • We need to learn from our failures as well as our successes. • Successful systems change requires vision, strategy, leadership and tenacity • Policy needs to be delineated into operational objectives and strategies • Horizontal integration at a Meso level and care coordination at a Micro-level is critical but so are clear Maco-level policy settings and resource commitment in the implementation process. Lessons learned • Lack of priority given to rapid gain, consumer focused initiatives • Work needed to be done to clarify and communicate the roles of the stakeholder group vis a vis ”working partners” and ” knowledge affiliates” • Insufficient attention to specifying and supporting common care pathways • The MH Atlas could have been utilised as a basis for joint planning given the information contained in it relating to the services and staffing to be integrated. • Lack of clarity regarding working relationship of the UP to new funding programmes ~ PHNs, NDIS • There was a need for concrete and continuing support from LHD and Governance partners and direction and resourcing from the State • Structures can appear robust and enduring but are vulnerable to shifts in support and direction. Limitations None Suggestions for further research Research on integration needs to occur at Macro, MESO and Micro levels

Title: Regional planning and the Implementation of Integrated Mental Health Care: the experience of Partners in Recovery James A Gillespie
Introduction. Improved care integration is a core element for improvement of Australia’s mental health services. This requires fundamentally better links between health-focused care and social and community-based supports. The fragmentation of Australia’s health systems – ranging from a public hospital system funded and managed at state level and primary care at federal has created a series of fissures that have proved hard to bridge. Policy-makers have supported an institutional shift to local and regional action to overcome these historic splits. This paper uses an institutional analysis of the Australian mental health system to identify some long-term elements shaping this continuity. It uses a recent innovative program, Partners in Recovery (PIR), to test the ability of a focused program break through these obstacles. From 2014-19 PIR combined a mental health recovery-based approach with an emphasis on building constructive partnerships between competing mental health providers. PIR was one of the few initiatives in mental health that specifically aimed to bring together primary health care, mental health and non-health services. Its approach by-passed existing structures and used more flexible, locally based approaches aiming at system change. Theory/methods. Persistent failures to implement reform, despite widespread consensus on the need for change suggests deeper, systematic problems. The paper uses public policy institutional theory to identify structural problems facing mental health service integration. A narrative review of available evaluations of PIR programs across Australia assesses the degree action was based on knowledge of local services and problems. How far did each evaluated program identify bridging mechanisms across health and social policy and the mechanisms of ‘partnership’ between funding and delivery agencies in public and private (NFP) sectors? What information was used about local services to shape referral practices? What methods were used to gather information about the pattern of local services? Evidence from Integrated Mental Health Maps produced for PIRs is used to show local differences in services and programs across PIRs. Results. The evaluations had uneven information on the way individual PIRs tackled the problem of local knowledge and how they built referral networks. Approaches ranged from systematic mapping of mental health services through to more ad hoc or passive methods. Conclusions. The variation in methods make systematic comparisons difficult, but PIRs that started from a systematic approach to planning were less likely to have crises of overload or mismatches between client load and referrals. Lasting institutional changes were difficult due to the instability of the program and its final attempted integration into the very different National Disability Insurance Scheme. Limitations: The research is based on publicly available evaluations and other papers on PIR. These include a national evaluation, but the local evaluations cover only a minority of PIRs. Suggestions for future research: More work needs to be done on how new tools for mapping are used in policy and practice in developing regional and local approaches to service integration.

Introduction
Persons with severe mental illness [SMI] have multiple and complex needs which are beyond the scope of mental health services. As a result, they fall through the service gaps. The Partners in Recovery (PIR) initiative was set up by the Australian Government to improve care coordination between clinical and other supports to promote a community based recovery model for people with SMI. Gippsland Primary Health Network (PHN) was lead agency in Gippsland and has worked with Monash University to evaluate the initiative.

Practice change
The PIR initiative involved care coordinators who worked with clients to develop a care plan based on their unmet needs; then brokered services from relevant agencies in accordance with the plan and monitored change in needs over time.

Aim and theory of change
Needs listed on the CANSAS were aligned with those on Maslow’s hierarchy suggesting that when lower level physiological needs were met, it would be easier to meet higher level needs. Hence meeting accommodation and food needs would enable meeting other safety needs.

Targeted population and stakeholders
Adults with SMI in Gippsland were eligible for the initiative.
Stakeholders included consumers and carers, Gippsland Primary Health Network, community mental health services, mental health community support services and the Department of Health and Human Services.

Timeline
The initiative was implemented across Gippsland from May 2013 to June 2019.
 
Highlights
Care coordination was effective in significantly reducing the number of unmet needs among persons with SMI. When accommodation needs were met, needs related to money, childcare, food, safety to self, education and access to other services were also met.

Sustainability
Implementing this care coordination model was found to be cost-effective when compared to not doing so. However, sustainability is dependent on funding for the care coordinator role.

Comments on transferability
The model is simple and transferable because it does not require integration of service systems. Multiple agencies are able to work together for the benefit of the client without interfering with their system fidelity.

Conclusions
The PIR initiative was effective in reducing the unmet needs of persons with SMI in Gippsland.

Discussion
Implementing the PIR initiative in Gippsland benefited not only clients and carers but also service providers. It addressed an unmet service need for persons with SMI and demonstrated that addressing accommodation needs facilitates meeting other needs. A commitment from funders and government is necessary to enable these learnings to be incorporated into routine services.
The Fifth Mental Health and Suicide Prevention Plan and the deliverable of regional Mental Health and Suicide Prevention Plans, to be jointly developed by PHNs and Local Health Networks, provide a starting point for this to occur.

Lessons learned
Improved care coordination is necessary to address the multiple and complex needs of persons with SMI and needs to be incorporated into routine mental health services.
Addressing accommodation needs must be a priority for people with SMI as it facilitates the meeting of other needs.

Introduction/Background:
The Health Independence Program (HIP) at Werribee Mercy Hospital (WMH) is an integrated multidisciplinary model of care providing a responsive and flexible approach between acute health services and community and social support services.
Problem statement
A significant number of HIP clients struggled to engage and achieve their physical rehabilitation goals due to the impact that chronic illness had on their mental health. ANMJ suggest ‘In Australia, the separation of mental and clinical healthcare funding has made integration of care impossible to achieve in the practical setting’ (ANMJ, 2015). What, if any assessments and treatment options could be considered to support the clients attending HIP?
Aim & theory of change
The Kessler Psychological Distress Scale (K10) was identified as the most appropriate tool for use alongside HIP’s comprehensive physical assessment to integrate physical and mental health care within HIP and for the community stakeholders. The K10 is utilised within the GP practices and readily translates between sectors (Kessler, R.C., Andrews, G., Colpe, .et al 2002).
Targeted population and stakeholders
All clients attending HIP are screened using the K10 tool.
Stakeholders include HIP clinicians, WMH community liaison psychiatry, community psychologist and psychiatrists, generalist counselling staff at community health services and the GPs caring for these clients.
Highlights
· Innovation.
Using K10 provided for early identification/intervention of client’s mental health issues that could be addressed/treated during their physical rehabilitation episode. Communication and sharing of information was made easier with a screening tool that crossed all health sectors and provided dialogue between the client and their GP.
· Impact.
A calibrated response depending on the K10 score was established for all clients of HIP with appropriate treatment and referrals to services established. Clients were better placed to address their goals when attending HIP due to a more holistic approach. “ If I get my medication for depression right and feel better I won’t drink as much” (Statement by HIP client – Mary, April 2019)”.
· Outcomes.
Client’s self-reported greater autonomy to direct their care planning having addressed their mental ill health. Clients are empowered to act on recommendations i.e. speak with their GP re: care plan for psychological support.
Recognition of the extent of the issue - 30% of all HIP clients screened each month scored 30/50 or above in their K10 indicating severe mental ill health.
The service gap between physical and mental health services has been reduced leading to better communication and options for treatment.
Partnerships are established with internal and external agencies, i.e. GP’s improving and simplifying communication-using K10.

Conclusion:
Holistic care addressing both mental and physical health issues, it would appear, has the potential to improve the overall health outcomes for those with mental illness (The Lancet 2014).



References:
Australian Nursing and Midwifery Journal. Vol:22, 8 March (2015). Holistic care approach. Pg 38.

Editorial, The Lancet, (2014); 384:1072


Kessler, R.C., Andrews, G., Colpe, .et al (2002) Short screening scales to monitor
population prevalences and trends in non-specific psychological distress.
Psychological Medicine, 32, 959-956.