Best Practices in Mental Health Reform: Discussion Paper

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3. Phase I Findings -- Best Practices

The Phase I Review summarized proven and promising approaches for providing individual supports, inpatient/outpatient care, crisis response, housing, employment and self-help. The Review also identified practices related to policy, governance and funding, evaluation and human resource management which promote change and progress in mental health systems reform. As noted, research evidence was stronger for some types of services and supports than others, and the level of rigour was acknowledged when best practices were identified.

In the area of individual support and case management, a strong body of research evidence demonstrates that Assertive Community Treatment (ACT) programs are superior for improving clinical status and reducing hospitalization. A smaller body of studies show that rehabilitation and personal strengths case management models are appropriate for serving individuals with less intensive needs and can help them to improve functioning, residential stability and independence.

While research evidence is weaker in the area of crisis response, studies support the use of crisis response programs to divert people from inpatient hospitalization using minimally intrusive options. Components of the crisis response continuum include telephone crisis and warm lines, mobile crisis units, crisis residential services and psychiatric emergency services in hospitals. Crisis programs need to incorporate evaluation protocols to generate more knowledge about the nature and impact of these programs.

In the area of housing and community support, studies tend to be quasi-experimental and cross-sectional. Research in this area indicates that a range of different housing alternatives needs to be provided, but that there should be a shift in resources and emphasis to supported housing. The supported housing approach encompasses use of generic housing widely dispersed in the community, provision of flexible individualized supports which vary in intensity, consumer choice, open-ended tenure and provision of case management regardless of whether a client moves or is hospitalized. While supported housing is appropriate for many individuals, an array of staffed community residential housing must also be available for those with special needs. Studies have found that assertive community treatment is effective for very difficult-to-house populations such as the homeless.

Research on approaches for delivering inpatient and outpatient services is extensive and fairly rigorous. Best practices derived from this research include moving long stay patients from psychiatric hospitals into the community, with carefully planned transitions to alternative care models. Programs which provide alternatives to inpatient admission and care include home treatment and day hospital. Keeping length of stay as short as possible is appropriate most of the time. New service delivery models are needed that can link family physicians with mental health professionals.

While there is variability in the quality of studies to evaluate self-help and other consumer initiatives, findings support the need to fund and nurture the development of alternative supports. The general public and mental health professionals need to be educated about the value of self-help, and steps should be taken to attract and train strong leaders. Evaluation of consumer initiatives using methods that are both scientifically sound and acceptable in such settings are needed. Consumer participation in program governance and delivery was not reviewed in this section but is discussed in sections on system policy, human resource management and evaluation.

Research on family self-help is limited in quality and quantity but provides direction for identifying best practices. Family groups should receive funding and should participate in planning and evaluation of care delivery. More evaluation of family self-help using acceptable methods is encouraged.

Rigorous studies of vocational and educational services provide evidence for shifting from traditional vocational services to supported employment. This approach includes provision of continuous, time-unlimited individual support and attention to client preferences. Supported education and social recreational programs are promising models in need of further evaluation.

To identify best practices in system level reform, reports on system strategies used in other jurisdictions were reviewed.

Studies demonstrated the importance of having a free-standing mental health reform policy that is supported by an explicit vision and quantifies the magnitude and pace of change for reform. Stakeholder participation in policy development and a planned approach for implementation, for example through legislation, are also essential to successful reform. Policy should support the development of services and supports that go beyond formal mental health care. Key policy issues to be addressed include reallocation of fiscal and human resources, coordination of care, integration of services and supports, consumer and family participation, and monitoring quality and outcome.

A number of best practices were identified in governance and funding. Of critical importance is the creation of a separate, single funding envelope that combines various funding streams for delivery of mental health care. Funding allocations should be linked to the unique characteristics and needs of area residents, and program allocations should be tied to desired program and system changes. The benefit of establishing mental health authorities at regional or local levels with responsibility for planning, organizing and monitoring services and supports, and for dispensing funds, has been demonstrated. A variety of fiscal and clinical tools can be used to achieve more integrated care delivery. A consumer-centred information system is essential to support decentralized planning, funding and management of the system.

A well functioning mental health system requires comprehensive monitoring and evaluation. Assessment must occur at the consumer, program, system and population level, with the ongoing involvement of the full range of stakeholders, including consumers and families. Program activities and outcomes should be monitored on a routine basis, and results cycled back to stakeholder groups for continuous improvement. Adequate resources are needed to fund evaluation activities and an information system that has common and local data elements must be developed.

Staff redeployment and training are key concerns in the human resource area. A best practice labour strategy for staff redeployment should clearly articulate the time frame, pace and magnitude of redeployment, allocate adequate funds to cover related costs, and explicitly address issues related to collective agreements. A training strategy also should include reskilling initiatives. Strategies to enhance consumer involvement as providers are needed.