Review of Best Practices in Mental Health Reform

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• II Summary of System Reform Srategies Policy
• Governance and Fiscal
• Evaluation
• Human ResourcesNext steps

II Summary of System Reform Srategies

Best administrative practices for creating an environment conducive to implementing mental health reform encompass policy; evaluation; governance and funding; and human resource planning as follows:

Policy

Key Elements of Best Practice

• There is a free-standing mental health reform policy in place.
• The mental health policy is supported by an explicit vision that the various stakeholders are aware of and in agreement with.
• The full range of stakeholders, including consumers and families is involved in the ongoing development and evolution of policy.
• The policy supports development of services and supports that go beyond the formal mental health system, for example consumer and family initiatives, and informal supports.
• The policy defines measurable targets that quantify the magnitude and pace of change for reform.
• There is a planned strategy for implementing policy, for example through legislation and through officially mandated planning documents.
• Policy covers issues such as priority setting, reallocation of fiscal and human resources, coordination of care, integration of services and supports, consumer and family participation, monitoring quality and outcome.

Governance and Fiscal

Research Evidence

Empirical evidence from system evaluations indicate that:

• Needs-based resource allocation is more effective in matching resources to local consumer needs than approaches based on historical funding levels and provider behaviour.
• Local mental health authorities and single funding envelopes can create more integrated mental health delivery systems, shifting resources from institutions to community, expanding community services and increasing continuity of care.
• Funding strategies that attach reimbursement to individuals have many advantages but are still limited by our capacity to calculate appropriate rates of reimbursement, monitor performance and develop/manage provider contracts.
• Performance contracts can be used to reduce hospital use and shift resources into community supports.

Evidence from controlled and uncontrolled trials indicates that:

• Despite implementation problems, non-profit capitation programs for people with severe mental illness can successfully direct care to a neglected population, reduce hospital use, increase use of community supports and lower overall treatment costs.

Key Elements of Best Practice

At a provincial level there is:

• leadership which has an explicit and shared vision with all stakeholders for how the reformed system should be organized and what outcomes are desirable for people 
• a strategy that includes creating decentralized structures for managing local mental health care delivery
• monitoring responsibility (e.g., through allocations, standard setting, audits)
• separate, single funding envelope that combines various funding streams for delivery of mental health care.
• legislation or policy directives to preserve the mental health reform strategy and envelope 
• capacity to develop joint initiatives with other government departments

At a regional and/or local level there is a mental health authority in place that:

• serves as a clear point of responsibility for people with serious mental illness.
• controls a single, combined envelope for funding mental health care
• has responsibility for planning, organizing and monitoring services and supports, and
• dispensing funds
• uses clinical, administrative and fiscal mechanisms to achieve more integrated delivery of care.

Funding allocations for particular geographic areas are linked with unique characteristics and needs of 
area residents.

Reimbursement mechanisms (e.g., performance contracts, capitation) are used to promote program and systems change. The needs of the consumer are always central in this process.

There is a strategy to rebalance spending and increase the proportion of total mental health funds spent on community services and supports.

A consumer-centred information system supports decision-making in planning, funding and managing the system.

Policy and legislative mechanisms preserve the mental health envelope and prevent losses due to
downsizing in the institutional sector.

Evaluation

Key Elements of Best Practice

Provincial or regional level:

• There is leadership and accountability for monitoring the effectiveness of mental health services at the provincial level.
• There is a comprehensive program in place for monitoring and evaluation. This program could be part of Mental Health reform legislation.
• There is use of both internal and external evaluation mechanisms (to satisfy needs for monitoring and for new knowledge development).
• Consumers, families and the full range of stakeholders have ongoing input and participation in evaluation planning.
• There is regular monitoring of all mental health programs and supports according to preset goals, performance measures (benchmarks and targets) and time lines.
• Assessment occurs at different levels - for example at the consumer, program, system and/or population level.
• There is a useful information system that has common and local elements.
• There is a sufficient, protected evaluation budget.

Program level:

• Consumers, families and the full range of stakeholders have ongoing input and participation in evaluation planning.
• There are methods of monitoring process and outcomes on a routine basis.
• There are mechanisms for feeding results back to stakeholder groups for continuous quality improvement.
• Program evaluation plans and information systems comply with broader evaluation strategies and also meet program needs.
• Program funding is sufficient to support evaluation activities.

Human Resources

Key Elements of Best Practice

There is a labour strategy to facilitate redeployment of staff that:

• addresses issues such as the impact of collective agreements, loss of seniority, differences in levels of compensation,
• clearly articulates the time frame, pace and magnitude of redeployment;
• allocates adequate funds to cover the costs of redeployment.

There is a training strategy for developing the skilled labour force needed to implement mental health reform that includes both training and reskilling initiatives.

There are strategies in place to enhance consumer involvement as providers - e.g., through training, by including experience as an employment criterion.

Next steps

This literature review is the first phase of a project to define best practice. The second phase will be a situational analysis of best practices in mental health reform in Canada. The intent is to provide specific examples and applications of best practices from the provinces. In particular, we want to be able to better describe how similar services and supports and system approaches have been fostered and developed as a part of mental health reform.

In a subsequent document, these descriptions will be compiled and discussed. In addition, three best practice strategies will be examined more closely and used as case studies of the process of mental health reform. The situational analysis will be used to illustrate and highlight activities across Canada that are in keeping with our current state of knowledge about mental health reform. They also will be used to identify the key factors and circumstances that facilitate or impede the development of best practices in mental health systems.

A final phase will synthesize the findings from the literature review and the situational analysis to develop promising approaches for mental health reform, appropriate indicators for systems and important characteristics of 'best practice' which lead to improved mental health outcomes.