Best Practices in Mental Health Reform: Discussion Paper

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2. Project Methodology

This report completes a three-part project conducted by the Health Systems Research Unit (HSRU), Clarke Institute of Psychiatry for the Federal/Provincial/Territorial Advisory Network on Mental Health (ANMH) on behalf of Health Canada.

Phase I resulted in a critical evidence-based review of the current state of knowledge about 'best practices' relevant to mental health reform, with a focus on chronic and severe mental illness. The review examined knowledge about efforts to:

• improve the organization, efficiency and effectiveness of mental health systems, and
• find better and more appropriate models of care for persons with severe mental illness, with an emphasis on community-based services.

In assembling evidence on program models, our intention was only to review studies and reports that met accepted standards of methodological rigour, using criteria as specified in Burns (1989), Forchuk and Roberts (1992), Hall et al. (1994) and Wortman (1994). Both qualitative and quantitative studies were reviewed, as both types of research can offer valuable information if the method is appropriate to the research question. Because the quality of available evidence varied across program domains and was weaker for some (e.g., crisis response) than others (e.g., case management), our inclusion criteria necessarily became more flexible. Summaries of research findings reported in the Literature Review (ANMH) are careful to acknowledge the strength of the studies on which they are based.

A less scientific methodology was utilized for assembling knowledge on systems level strategies. For each area of system intervention - policy, governance and funding, monitoring and evaluation, and human resources - strategies successfully used in other jurisdictions were summarized, with emphasis on critical issues and lessons learned. Key articles and documents (published and unpublished) which analysed experiences of other jurisdictions were reviewed.

Phase II of the project was a situational analysis of mental health reform policies, practices and initiatives in Canada which approximated 'best practices'. Each provincial/territorial ANMH representative nominated initiatives from their region which conformed to the 'best practices' strategies identified in Phase I. National initiatives were nominated by the entire ANMH group. Since resources did not permit a follow-up of all nominated strategies, selections were based on:

• representativeness in terms of regions of the country and key programs/strategies of mental health reform;
• conformity with the elements of best practice outlined in the literature review.

For each selected initiative documents were reviewed, interviews were conducted with key informants, and some sites were visited for more intensive coverage. Not all provinces submitted nominations nor did submissions represent every best practice program/ strategy. As a result, not every region was represented in the situational analysis and examples of some important strategies, e.g. system-wide evaluation, were not included.

The purpose of this report is to synthesize the findings of two previous phases and to summarize what has been learned, identify what facilitates innovation and change in achieving mental health reform, and recommend future priorities for action and change. We begin with a summary of Phase I findings, including presentation of a checklist that could be used to assess a jurisdiction's progress in mental health reform.