Outcomes of a care coordinated service model for persons with severe and persistent mental illness: A qualitative study

Abstract

Background:

Owing to difficulties faced by individuals with severe and persistent mental illness (SPMI) in accessing multiple services, the Australian Government trialed a care coordinated service model called the Partners in Recovery (PIR) initiative.

Material:

A total of 45 stakeholders in Gippsland were asked what difference the initiative had made.

Discussion:

The PIR initiative benefited not only clients and carers but also service providers. It addressed an unmet need in service delivery for individuals with SPMI.

Conclusion:

The PIR initiative has filled a gap in delivery of care for individuals with SPMI in Gippsland.

Keywords

Care coordination collaborative care mental disorders personal recovery rehabilitation non-clinical mental health services

Introduction

Individuals are said to have severe and persistent mental illness (SPMI) when they have ‘severe symptoms or severe difficulty in social, occupational or school functioning’ together with treatment that has lasted for 2 years or more (Ruggeri, Leese, Thornicroft, Bisoffi, & Tansella, 2000). Such individuals require more intensive support to effectively address the complexity of their needs (Berren, Santiago, Zent, & Carbone, 1999). Recovery in such persons is described as ‘a journey, characterized by a growing sense of agency and autonomy, as well as greater participation in normative activities, such as employment, education, and community life’ (Drake & Whitley, 2014).

Recovery-oriented interventions therefore require a coordinated and individually tailored approach. However, these are not known to be routinely available (Drake & Whitley, 2014; Horvitz-Lennon, Kilbourne, & Pincus, 2006). Individuals with SPMI are traditionally managed by mental health case managers who are responsible for their care coordination. However, owing to their heavy workload, their role has reduced to focusing on medication and appointment compliance, being watchful for early warning signs and working with those in crisis (Sutton, Isaacs, Dalziel, & Maybery, 2016). Clients are therefore expected to identify their needs, and contact the different services that could address them without any support from the system. Most clients with SPMI find it difficult to achieve this. As a result, they do not access services according to their need and eventually fall through the system gaps (Berren et al., 1999).

Due to growing concerns about the difficulties faced by individuals with SPMI in accessing multiple services, the Australian Government trialed a care coordinated service model called the Partners in Recovery (PIR) initiative. The PIR initiative aimed to support a better integrated mental health care system. In doing so, the initiative was expected to improve referral pathways, strengthen partnerships between the different services that would work together and promote a community-based recovery model. The initiative was implemented nationally from 2014 to 2016 to support an estimated 20,000 individuals with SPMI in defined catchment areas by 48 suitable non-government organizations (Australian Government Department of Health, 2015). One such catchment was the Gippsland region of Victoria, Australia.

This research was part of a larger evaluation of the PIR initiative in Gippsland. It reports on the views and experiences of stakeholders on this new initiative. It is now widely recognized that individuals involved in the implementation of a program play a critical role in its success or failure (Damschroder et al., 2009) and their opinions are considered to be vital in determining the usefulness of such interventions (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). The quantitative component of this research that measures the real-world impact of the PIR initiative on consumer needs has been submitted for publication elsewhere. An outline of the PIR initiative in Gippsland is given below.

The partners in recovery initiative in Gippsland

The Gippsland region includes the entire south eastern corner of Victoria covering 41,600 km² with a population of over 270,000 (State Government of Victoria, 2014; Figure 1). The Area Mental Health Service provides public clinical mental health services across Gippsland and is based at the Latrobe Regional Hospital. The non-clinical component of public mental health services is provided by the non-government community managed sector or community mental health support services.

Figure 1.

Map of Gippsland, showing location of mental health services.

Setting up the PIR initiative

The lead agency for PIR initiative in Gippsland is a regional health planning organization called Gippsland Primary Health Network (GPHN), previously called Gippsland Medicare Local (Gippsland Primary Health Network, 2015). In order to govern this project, GPHN formed a regional PIR Consortium with the Community Mental Health Support Services (CMHSS) and the Area Mental Health Service. The CMHSSs are referred to as Support Facilitator Organizations (SFO) for the purposes of this initiative. These not-for-profit organizations are skilled in recovery-focused mental health service delivery.

Each SFO appointed between four and six support facilitators (SF) who were mostly females (90%), aged 30 years and older, the majority (66%) of whom had worked in the mental health sector for more than 3 years in roles that ranged from case manager to social worker. All SFs received a centrally designed and administered training package. They were expected to have a good knowledge of the local services and resources, be competent communicators and have strong social skills. Their role was to develop and establish partnerships with different service providers as well as develop, monitor and review shared care plans for their clients (Sutton et al., 2016). The PIR initiative officially commenced in March 2014 and targeted at least 264 people in Gippsland. The initiative was intensively advertised on local TV and radio as well as with posters. SFs also made presentations about the initiative to the various services and health organizations in Gippsland. Information about this initiative was dispersed by word of mouth as well. Referrals to Gippsland PIR progressively increased over the first 12 months.

Referral to the PIR

Clients with SPMI either self-referred or were referred by family members or organizations to the SFO in their area. Clients were accepted into the initiative if they satisfied the following five criteria: were experiencing SPMI; had complex needs that required input from multiple agencies; required substantial support to engage with these agencies, to meet their needs; had no existing coordination arrangements in place, or arrangements were not meeting their needs, or were contributing to the problems experienced by the person; and were agreeable to participation in the PIR initiative and provided informed consent to do so (Primary Health Network Gippsland, 2016).

Assignment of SF

Once a client was considered to be suitable for the PIR initiative, they are assigned a SF who, through a series of meetings with the client, identified their various needs and contacted services that could address those needs.

Formation of the care team

The SF was responsible for forming the care team. If the client was already working with different services, the SF invited the client along with workers from the various identified services (other service providers (OSPs)) to be part of a care team. On the other hand, if the client was not already engaged with other services, the SF had to first identify the client’s needs and the services that could address those needs before inviting them to be part of the care team.

Provision of holistic care

Giving the client the first voice, the care team developed a care plan for the client. Once the care plan was finalized and approved by the client, each member of the care team took responsibility to deliver their component of the plan in collaboration with other care team members. Facilitated by the SF, care teams met regularly with the client to monitor progress. In certain situations, the role of coordination was passed on to the service provider who the client most frequently interacted with. Service providers whose services were no longer needed by the client withdrew from the care team and new providers joined to address newly identified needs. Finally, when clients felt that they were capable of accessing the different services without assistance, they were withdrawn from the PIR initiative.

Methods

Study design

This was a qualitative study underpinned by ‘qualitative description’ (QD). QD aims to ‘present a rich, straight description of an experience or an event’ (Neergaard, Olesen, Andersen, & Sondergaard, 2010). When employing this research design, the researcher stays close to the data by avoiding excessive interpretation (Sandelowski, 2000). The design therefore presents rich information that may be grounded in cultural and environmental contexts. QD is advantageous when conducting research aimed at improving interventions or decreasing health care barriers for disadvantaged populations (Sullivan-Bolyai, Bova, & Harper, 2005) and is therefore useful in obtaining information that is particularly relevant to service providers and policy makers (Sandelowski, 2000). QD has been used elsewhere in similar studies (Isaacs, Maybery, & Gruis, 2012).

Participants

Participants in this study included coordinators of the initiative from GPHN, SFs and their managers, OSPs as well as clients and carers who were involved in the initiative. Semi-structured interviews were conducted by two researchers with 45 stakeholders (Table 1).

Table 1.

Distribution of participants according to job description and role.

Participant type		Number
SFOs	Support facilitators	15
SFOs	Managers	2
Other service providers	Housing workers	3
	Clinical mental health case managers	4
	Drug and alcohol worker	1
	Family services	1
	Private psychologist	1
	Personal helpers and mentors program	2
Clients		7
Carers		6
GML staff		3
Total number of participants		45

SFO: Support Facilitator Organization; GML: Gippsland Medicare Local.

Data collection

This study was undertaken from February to May 2015. Participation forms (explanatory statements, consent forms and reply paid envelopes) were left at each SFO. Separate participation forms were provided to the SFOs for clients and carers as well as for OSPs. SFs distributed these forms to clients of the PIR initiative and carers with an invitation to participate in the evaluation. Only those carers who regularly represented a client at care team meetings were invited to participate in this study. In such cases, the client was not interviewed. This was done to obtain a specific carer perspective on the initiative. Clients and carers returned signed consent forms to the Chief Investigator using reply paid envelopes. Dates and times for interviews were finalized between researchers and participants over the phone. As part of the interview, which covered various aspects of the PIR initiative, participants were asked, ‘What difference, if any, do you think the PIR initiative has made?’ This article only describes participants views related to the above question. Interviews were conducted at the premises of the respective organizations or by telephone and lasted between 20 and 60 minutes. Ethics approval for the study was obtained from Monash University Human Research Ethics Committee (CF15/463 – 2015000230).

Data analysis

All interviews were professionally transcribed and subjected to thematic analysis as described by Braun and Clarke (2006). Since the focus of this research was to obtain general feedback from all key stakeholders, responses from both service users and providers were analyzed as one data set. Data that related to the question, ‘What difference, if any, do you think the PIR initiative has made?’ were initially extracted from each interview manuscript. After reviewing the data set, chunks of data were assigned a code. Once all data were coded, data with similar codes were grouped into categories (Green et al., 2007). Categories were then refined by modifying or combining them. Groups of related categories were combined to form themes. Key quotes from each data category were then extracted. All authors certify responsibility for this article.

Results

Two themes emerged from the data. They were ‘service system outcomes’ and ‘client outcomes’. These themes illustrate the difference the PIR initiative made to mental health service delivery and to clients with SPMI in Gippsland. Categories and representative quotes for service system outcomes are listed in Table 2 and that for client outcomes are listed in Table 3. A description of each theme is given below.

Table 2.

Categories and representative quotes for service system outcomes.

Theme	Categories	Representative quotes
Service system outcomes	An unmet need has been addressed	I’ve seen a lot of services go, ‘Oh, Thank god!’ It just needed some help to gather the services together and to get them working in [unison] and I’ve seen a lot of really good positive results come from this program. (SF 14)
	Better interservice collaboration	I think that it’s been a really good program for services to get an understanding of what all of us do. You might say, ‘Well you’ve got a withdrawal nurse’, but what does a withdrawal nurse do? So it also teaches us what services are really appropriate … (SF 1)
	Better interservice collaboration	I personally believe that it’s probably strengthened relationships between the organisations. I like to think I’ve got some really good contacts and strong relationships with people, particularly at [housing service], [Community mental health service] and [Drug and alcohol]. (SF2)
	Team approach to patient care	It’s very much a team approach, but because these people are so complex [it] works really well not only from an organizational point of view but from bouncing off each other and picking each other’s brains … and I guess sharing the load in some respects as well. (OSP 7)
	Team approach to patient care	I like the fact that the responsibility is split between people. So there is much less burnout. (SF 2)
	No duplication of services	The other thing is non-duplication of service, I find that really good. Everyone contributes to one plan. There’s great communication, everything is distributed and there’s an understanding. (SF 1)
	No duplication of services	It’s something we’ve always been concerned about … the replication of service … (OSP 12)
	Better understanding of client’s history and needs	Sometimes the client might be suggesting different things to different workers and you find you’re all kind of chasing your tail. I find with this kind of model … that it avoids a lot of that and especially if the clients are involved in the care team too. (OSP 5)
	Better understanding of client’s history and needs	It also has been good in terms of understanding the history of a client. In the meeting, different people contribute different things and a picture evolves that previously couldn’t be seen and you get those missing bits about a person’s history. (SF 3)

Table 3.

Categories and representative quotes for client outcomes.

Theme	Categories	Representative quotes
Client outcomes	Care has become more client driven	It was coming more from what the case manager thought was good for the client, rather than what the client thought was good for them. That is what I’m gaining from my clients. (SF 8)
	Care has become more client driven	When something new starts it becomes a proliferation of management structure and not actually service delivery, but in the situation we’ve found ourselves down here, it’s been delightfully client orientated and active in delivering meaningful client services. (OSP 12)
	Clients feel valued	Well, a lot of clients have told me they’re very happy because they say, ‘Oh … the best thing that’s ever happened to me’. Well I’ve only done a really little bit, but it turns out that’s more than anybody else has done. And that’s about listening and showing respect and treating [them] as a human. (SF 9)
	Clients feel valued	Sometimes it’s in smaller things that they’ve felt understood and they felt valued which again is so central to a person’s recovery I think. It’s not just the services you put on board, it’s the way you really attempt to be a partner. (SF 3)
	Clients are more confident in managing their illness	The difference that I think I’ve made to this client is that basically she is a lot more confident; she’s a lot more self-assured; she’s having less bad days because she’s able to manage those bad days. So it’s those tools and skills that I’ve taught her that she’s now able to do for herself. (SF 11)
	Clients are more confident in managing their illness	For one [client] in particular … She’s not necessarily a confident enough person herself to be explaining everything to everyone all the time. So I think she’s felt confident and comfortable that that’s happening for her if she can’t do it. (OSP 5)
	Improved access to services	I’ve never spoken to a psychologist before and I’m actually getting contacted by [the hospital] about a neurologist as well. So these are things I’ve never had access to before … maybe because of the stigma – I was worried about ending up in a rubber room. (Client 3)
		There [were] some major decisions to be made and finding your own way through … where you have to go is impossible really because you don’t know what services to follow up unless it’s by accident. But just having it all coordinated together was easy … (Carer 3)
		I’m very reluctant with GPs and just help remind me [sic] and say, ‘Well let’s make the phone call now.’ and little things like that, which helped me to help myself as well as them linking me in with services. (Client 1)
	Clients accessed education and accommodation	Well I’ve got one lady who has been unemployed. We’ve got her onto a course; she’s 30 years old – to get a Certificate III … to improve their employment chances and at the end of the day people need to work … and if they’re going to get over their addictions – if there’s nothing to do, they fall back in a hole. (SF 9)
	Clients accessed education and accommodation	With the help of Partners in Recovery, I’ve got a stable home that I can’t be thrown out of, and now I’m entering into education which is just brilliant. I can see a light at the end of the tunnel which I didn’t have before. (Client 5)
	Clients moved from despair to hope	Oh a huge difference, probably … suicide … It’s a great help. It’s been fantastic, really. It’s the emotional support and … letting you know the services and things out there for you. I’m really grateful for that, you know. I can’t say how much … (Client 4)
	Clients moved from despair to hope	Look, they’ve been a pivotal part of my life … to help me get to a better place. Where I was sitting 12 months ago was really sad. I was homeless, I was looking at throwing myself off a bloody bridge because I wasn’t prepared to be homeless at 43 and lose everything. Through accessing [the PIR initiative] … I’ve got my life back and I’ve got hope, which is something you just don’t get. (Client 5)
	Clients have a better quality of life	Hugely beneficial, mate! Without them, quality of life wouldn’t be anywhere near as good as it is now. (OSP 12)
	Clients have a better quality of life	The Partners in Recovery program facilitates a speedier recovery and if recovery is a stretch goal because the mental illness is persistent, then it just provides a much improved quality of life for people much sooner than it would otherwise. (OSP 10)
	Reasons for poor outcomes	I’ve [had a client] … she has a drug dependency and she went from being in a stable environment back into that particular environment and when she made that transition I only ever saw her one more time, and I have tried to contact her, tried to engage her and I just have been unable to. (SF 11)
		I’ve got a client at the moment who is withdrawing from one service after the other … And I’ve actually talked to [her] and she didn’t do that for a period of time. Then a couple of services let her down … you can’t control what happens in other services and how they respond to your client. (SF 3)
		We’ve got one woman [who] has very, very little involvement with her care … But having said that, she’s a mother of nine children who are all at risk of [child protection] intervention. They’re a really complex family to work with. (SF 2)

Service system outcomes

This theme relates to the views and experiences of participants on the impact of the PIR initiative on the service system and delivery of care. Overwhelmingly, the response to the introduction of the PIR initiative was very positive with most respondents complimentary of the new approach. SFs indicated that service providers were very appreciative of this model of care and welcomed it. They felt that an unmet need had finally been addressed. Although there were several different services operating in the region, they did not work together until now. This is due to differences in philosophy, modus operandi and accountability to different levels of government and funders. As a result, they did not know anything about other services that the consumer needed or was accessing. This led to a lot of duplication and frustration for service providers. The PIR program enabled the services to work together (Table 2). Furthermore, this interprofessional collaboration enabled the SFs to understand the work of other services and develop good contacts and working relationships with them. The collegiality of working within and being supported by a team as well as the team approach to patient care invigorated both SFs and OSPs. Sharing the workload appeared to protect against burnout and staff turnover. It was also indicated that when working with clients in isolation, it was often difficult to know their full history and what was happening with other aspects of their lives. Discussions at care team meetings provided for a better and more comprehensive understanding of the client’s history and needs.

Client outcomes

This theme relates to views and experiences of participants on client outcomes. Although there were instances where poor outcomes were observed, outcomes for clients were considered to be mostly positive.

Both SFs and OSPs felt that care had become more client driven. This was a welcome change since previous experience suggested that new programs involved mostly re-organization of the administrative structure with little change in the way services were delivered to clients. Clients who until recently felt excluded from the decision-making process were now being included as a key decision maker in their care plan. Furthermore, when clients realized that the SF and the care team gave priority to what they wanted, they grew in self-confidence and were able to develop the tools and skills to be able to manage their difficult days better. Clients who were more timid also felt reassured that their care was being managed well.

The initiative also enabled clients to overcome the stigma that prevented them from accessing mental health services. Carers indicated that care coordination by the PIR team made navigation through the maze of services much easier. Clients who were previously reluctant to meet with a doctor and other clinicians felt more willing to do so owing to the assistance from the SF. In addition, some clients have had the opportunity to enroll for an employment-oriented course and obtain stable accommodation. These were significant milestones in the recovery journey of these individuals.

As a result, the PIR initiative brought hope to the lives of individuals living with SPMI. Some clients spoke of how the emotional support they had received and the awareness they had obtained about the various services available was the ‘difference between life and death’. They spoke of getting back hope from a position of despair. Engaging with the PIR initiative had also fast tracked the recovery journey of some clients and for those whose recovery journey was expected to take long, the PIR initiative certainly improved their ongoing quality of life.

Despite all the positive outcomes, the initiative was unable to help some clients. For instance, individuals with drug dependence and those who refused to engage with the SF despite multiple attempts were often lost to follow-up. Although the PIR initiative was able to link clients into service providers, a lack of available services itself continued to let clients down. As a result, they became disillusioned and disengaged from the initiative. There were still others who simply could not cope due to the complexity of their difficulties.

Discussion

This study explores the views and experiences of stakeholders on the care coordinated model adopted by the PIR initiative in Gippsland, Australia. The findings provide a comprehensive understanding of the advantages of the model as data were obtained from a broad range of stakeholders with different perspectives. Overwhelmingly, participants indicated that the initiative had positive outcomes for clients and carers as well as health professionals involved in the care of individuals with SPMI. This study has demonstrated that the care coordinated service model adopted by the PIR initiative has significantly improved the quality of care provided to clients with SPMI in Gippsland.

This model was recovery focused. For instance, emotional and other support received from SFs was described by clients as being the difference between ‘despair and hope’, between ‘death and life’. Clients also spoke of feeling valued and listened to and of being encouraged to make decisions about their own life. This has been referred to as a ‘positive culture of healing’ (Fisher, 1993; Jacobson & Greenley, 2001). In addition, once clients were able to overcome the stigma associated with their disorders and gained a better understanding of their illness, they felt empowered, to better engage with services. This was evident from their improved ability to keep appointments and their confidence in discussing their issues with doctors and psychologists. In addition, the PIR initiative enabled clients to enroll into employment-oriented courses and secure accommodation. These outcomes align with the human rights agenda in mental health care which refers to enabling clients to have equal access to social conditions such as education, employment and housing (Jacobson & Greenley, 2001). The PIR initiative also fostered the development of a collaborative partnership between clients and service providers rather than a hierarchical one where clients are told what to do. Jacobson and Greenley illustrate the conditions of recovery from mental illness such as empowerment, hope, human rights and a positive culture of healing. These conditions were met by the initiative in Gippsland (Jacobson & Greenley, 2001).

Recovery is different for each individual and the future of mental health services is to promote each individual’s recovery process (Leamy, Bird, Le Boutillier, Williams, & Slade, 2011). Engaging with the PIR initiative enabled clients to fast track their recovery journeys and improve their quality of life.

This model also addressed the ongoing lack of meaningful care coordination for individuals with SPMI. This has been a long-standing unmet need of OSPs in Gippsland and is an important facilitator for the adoption of a new service or program (Mendel, Meredith, Schoenbaum, Sherbourne, & Wells, 2008). Despite the knowledge that working in a team with diverse expertise generates improvements both in patient care and organizational effectiveness (Horvitz-Lennon et al., 2006), a major reason why clients with SPMI are unable to access quality general health care is the lack of coordination between mental health and the general health sectors (Horvitz-Lennon et al., 2006). Through this initiative, OSPs were finally able to work in an environment of true interprofessional collaboration that demonstrated tangible benefits. For instance, working in a team enabled a better understanding of clients’ history and conditions which facilitated a more appropriate care plan. Face-to-face communication within the team also improved understanding of each other’s roles and limitations and service activities were not replicated since all team members worked to a single plan. An additional heartening outcome for SFs and OSPs was the camaraderie and support that care team members received from each other particularly when working through challenging situations.

These are significant outcomes since the opinions of individuals involved in implementing a new service are a key measure of the service’s success (Damschroder et al., 2009; Greenhalgh et al., 2004). These individuals are not passive advocates of the innovation. They evaluate the program, experiment with it and form their own opinions about it (Greenhalgh et al., 2004). The perception that implementing a program will result in a desired outcome is a key motivator for service providers to embrace it and therefore an important pre-requisite for its success (Lin et al., 2005). The findings of this study are also an indication that if routinized, this model is likely to be successful in achieving its desired outcomes. Although the PIR initiative did not work well for all clients, poor outcomes were mostly few and far between.

This study had a few limitations. For instance, it was conducted in only one rural region of Victoria. Hence, the findings may not be generalizable to other jurisdictions in Australia particularly to more remote catchments and urban areas. The small numbers of clients and carers who participated in the study overwhelmingly reported very positive experiences. Few clients had negative experiences. They were either lost to follow-up or were not contactable. However, SFs did provide some insight into the reasons for negative outcomes. The study was undertaken only 1 year after the initiative commenced and the findings may not reflect long-term outcomes and issues related to the PIR initiative. A key strength of this study was the engagement with all stakeholders in the PIR initiative. While larger numbers of consumers and carers would have been ideal, interviewing such a broad range of key stakeholders provided a comprehensive understanding of the PIR initiative from multiple perspectives and viewpoints.

Conclusion

This study suggests that the case coordinated service model adopted by the PIR initiative was widely accepted in Gippsland by clients, carers, SFs and OSPs. The model worked not only to promote recovery but also to improve the overall quality of service delivery in clients with SPMI. An additional outcome of this initiative was the coming together of services to work as a team that prioritized clients’ needs. The PIR initiative has certainly filled a gap in the model of delivery of mental health care for individuals with SPMI in Gippsland and appears to be a useful model for consideration in the future.

Footnotes

Acknowledgements

The authors would like to thank all the participants of the study and the support facilitator organizations, SNAP Gippsland, Inc., MIND Australia and Mental Illness Fellowship for their support and cooperation in undertaking this study.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Gippsland Medicare Local as part of a larger evaluation of the PIR initiative in Gippsland, Australia.

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