Abstract for Asia Pacific Conference on Integrated Care Conference: Achieving better value for people and populations Title: A Tale of Four Cities: Analysis of mental health services across four metropolitan Australian cities using the Integrated Atlas of Mental Health John Mendoza, Jose A Salinas-Perez, Luis Salvador Carulla, Mary Anne Furst. Introduction: Understanding the availability, capacity and accessibility of services in a geographically defined region for any given health need or condition is imperative for sound policy and service planning. Between the second half of 2014 and early 2018, systematic mapping of the mental health needs and services was undertaken in nine largely urban Primary Health Care regions using the Integrated Atlas for Mental Health. These nine regions were located in covered almost the entire greater Sydney region, over 65% of the greater Melbourne region, all of Perth and the north Brisbane region. Method: Service provision was analysed using the DESDE-LTC system for long-term care service description and classification that allows international comparison. Rates per 100,000 inhabitants were calculated to compare the care availability and placement capacity for children and adolescents, adults and older adults. Up to 15 population risk factors related to mental health, health status and mortality indicators were analysed for each region to highlight areas of higher need. Results were analysed along with the use of geo-spatial maps. Results: While the analysis shows only a small degree of variation in the availability of hospital based acute care, there are significant differences in the availability of other forms of residential services, particularly non-hospital forms. Low intensity outpatient social care services are also a dominant feature with few services related to employment or structured rehabilitation. High growth corridors in all outer metropolitan regions showed higher levels of risk for mental health and have significantly fewer services. Conclusions: Across Australia, different terms are used to describe mental health services, particularly in relation to different forms of residential care and outpatient services. The use of the Integrated Atlas methodology enables a clear and comprehensive understanding of the spectrum of services, the relative capacity of those services for a region, their location, the needs of the population and the ability to identify gaps. The Atlas data also provides a basis for better understanding mental health outcomes. This presentation will provide an analysis of the findings from the Atlas mapping in four different PHN urban regions and raise issues of equity of access to mental health care in Australia. Lessons Learned: Significant structural reforms with the implementation of the National Disability Insurance Scheme and changes to funding for community mental health organisations is impacting on the stability of mental health services. As these changes roll out, analysis of services and population needs is required to ensure closer alignment. Limitations: Only universal access specialised services for adults and children have been studied. Suggestions for future research: Analysis of relative technical efficiency, geographical accessibility and workforce capacity.

Introduction
Remote areas hold specific local and structural conditions that affect care availability and access, such as geography, population characteristics and service provision. Care in these areas is frequently scarce and fragmented and they are difficult to compare with similar areas in the same country. In order to plan effective integration, it is first necessary to perform a comparative analysis of the delivery system. This study aims to analyse the adult mental health service provision in three remote areas across the world.

Methods
The study areas are the Kimberley (Australia), Nunavik (Canada) and Lapland (Finland) between 2018-2019. These areas are characterised by extremely low population density and high relative rates of indigenous population. DESDE-LTC system was used for the standard description of the service delivery system for mental health care, in combination with socioeconomic and health context analysis along with geographical maps.

Results
The areas are deprived within their national contexts. Kimberley and Nunavik have a similar remoteness and their population centres are mainly connected by plane. Road passage in Kimberley and Lapland varies according to the season. Mental health services are mostly provided from the public sector completed with non-profit organisations. Specific cultural-based services for indigenous people have been identified in Kimberley, while every service is targeted to this group in Nunavik and none in Lapland.

Kimberley has two specialised acute units in a general hospital. The consumers who require medium and long stay are referred outside of the area. There are no community residences in the area. Mobile outpatient services are more developed than in the other areas.

Nunavik has two psychiatric beds in two general hospitals, while severe cases are referred to Montreal. Two psychiatrists visit the hospitals once a month. There are also several community residential settings. The remaining services are not specialised and deliver mental health first aid.

Finally, a general hospital with one acute unit and two medium-long stay units is available in Lapland in addition to community residences. The care profile is completed with day care services, and balanced number of mobile and non-mobile outpatient care services.

Discussions
The mental health care in Lapland is self-sufficient and its care pattern is similar to other Finnish areas, while Kimberley and Nunavik are especial cases in their jurisdictions and depend on external facilities for severe and long-term cases. The nonexistence of day care provision in the latter areas seems to be related to the isolation and dispersion of the population centres.

Conclusions
Local contexts are essential in the study of mental health service provision. The knowledge provided may support decision-making for mental health policy and planning in remote areas.

Lessons Learned
So far, service provision in remote areas has not received much attention even though their especial psychiatric morbidity. It is necessary to take into account local context.

Limitations
Only universal access specialised services for adults have been studied. The results cannot be generalised to other remote areas with different characteristics.

Suggestions for future research
Analysis of relative technical efficiency, geographical accessibility and workforce capacity.

Introduction:
Currently there is growing interest in providing integrated mental health care between hospital (acute residential care) and community-based services (… and other health systems). Mental health systems are complex due to the high disorder prevalence, socio-economic burden, stigma associated, and high gap of unmet population needs. Mental health can be considered an ecosystem related to, at least, physical health and social services ones. Decision support systems are robust tools for guiding and improving planning and management of health ecosystems by integrating methods like Bayesian networks. These models identify critical variables, domains and constructs and their corresponding causal relationships. The objective of this research is to design an integrated and integral theoretical Bayesian network for guiding mental health planning and management, and in consequence, improving mental health care delivery.

Methods:
The setting is the Mental Health Network of Gipuzkoa and Bizkaia (Basque Country, Spain). Data collection was carried out in 2013 for the Mental Health Atlas of Gipuzkoa and Bizkaia (2015). The main indicators are grouped in: availability, placement capacity, workforce capacity, discharges, average length of stay, readmissions, utilization of health day care services, and incidence, prevalence and visits for outpatient care services.
The domains, subdomains and constructs were standardized by using the DESDE-LTC codification system. The causal relationships were identified and described by using explicit expert knowledge from mental health managers and researchers from Spain, United Kingdom, Finland, United States and Australia. Expert knowledge was elicited by using the Expert-based Cooperative Analysis (EbCA) model. In addition, we consider the results obtained in two previous systematics reviews on Mental Health planning and management.

Results:
The analysis identified the following constructs: mental health promotion and mental disorder prevention, information for care, self-help and voluntary help, community pharmacy, primary care, outpatient care, day care and residential care, being these the core of the Bayesian network. The constructs are interrelated bi-directionally. In addition, causal relationships between the core and the ecosystems physical health and social services were identified, linking the Mental Health ecosystem with the health environment. The identified constructs were developed in domains and subdomains, according to the DESDE-LTC codification system, in order to represent the real status (availability and adequacy) of a specific Mental Health ecosystem. Finally, variables are the seeds of the Bayesian network.

Conclusions:
This is the first theoretical Bayesian network model that will let us to assess how balanced and integrated any real Mental Health ecosystem is. This model identifies the availability of the elements and their causal relationships can be used to assess an adequacy index according to the basic Mental Health community care model. The Bayesian network can be used in any Mental Health ecosystem worldwide.

Lessons Learned:
To improve mental health care planning and management, it is required to make evidence-informed decisions taking into account population needs, local characteristics and global influences.

Limitations:
The number of variables (seeds of the model) is critical as well as the limitations of the DESDE-LTC codification system that has to be extended to include other types of care.