Best Practices in Mental Health Reform: Discussion Paper

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8. Future Research and Knowledge Transfer

In this discussion document it has been argued that we have sufficient knowledge to direct mental health reform and identify strategies that will build integrated systems. Nonetheless, many questions still need to be addressed. To move ahead with the implementation of broad reaching reforms it is important to consider ways of continually learning about their impact and effectiveness.

8.1 Sources of Knowledge

In the literature review we focused on knowledge that is gained from medical and social science research. The situational analysis provided an opportunity to learn from the experiences that arise during actual applications in less controlled conditions. Future evaluation and research efforts will be enriched if they continue to incorporate the experiential knowledge of those who provide and receive the services and supports that are being studied. One way of accomplishing this aim is to conduct effectiveness studies using a combination of qualitative and quantitative methods (Goering and Streiner, 1996). Involving consumers in the design and conduct of evaluation studies further enriches the relevance and usefulness of the findings (Everett and Boydell, 1994).

8.2 Programs of Research

Services and Supports

There is still much to be learned about best practices concerning services and supports. As is clear from the literature review, our level of knowledge is very uneven from one area to the next. For those interventions where there is the strongest evidence concerning effectiveness (assertive community treatment, community placement of long-stay inpatients, supported employment) there is a pressing need for a more refined level of information about what works with whom. Research is needed which tests modifications of the models/ approaches to determine whether they work with special populations and how they might be applied in various settings or in more cost efficient ways. Methods of conducting this type of research are evolving and the next generation of studies will be expected to meet even higher standards. For services and supports where evidence of effectiveness is weaker, there is a need for more creative approaches to assess effectiveness when traditional randomized controlled trials are not feasible or appropriate (Orwin and Goldman, 1996). Appendix A is a compilation of directions for future research extracted from the research reviewed in Phase I.

System Level Strategies

System strategies have only recently been subjected to empirical examination and evaluation. In addition to ongoing monitoring of systems reform for the purposes of accountability and improved service delivery (see Chapters 9 and 10, Literature Review, ANMH) there is a need for health services research that has as its purpose producing valid and generalized knowledge for the field. Mowbray (1992) discusses conditions for facilitating implementation of programs of research that would play a significant part in restructuring public mental health systems. These include a clear articulation of the objectives of the reform strategy and the means that are expected to produce change. Utilisation of evaluation is also dependent upon having knowledgeable and motivated decision-makers who will incorporate the findings from such research into policy and practice. This means that evaluations should be structured to address the pressing concerns of those in governmental and administrative positions. Access, quality of care, cost and the potential adverse consequences of broad-based system reform (criminalization of the untreated mentally ill, homelessness, etc.) are examples of such concerns.

Challenges in Mental Health Systems Research

There are a number of challenges facing the emerging field of mental health services research (Mechanic, 1996). They include adjudicating between competing priorities, identifying the key elements in successful interventions, and defining outcomes more broadly to reflect consumer and family preferences and quality of life. Attempts to demonstrate that integrated organizational systems result in better client and family outcomes so far had have limited success. It may be that the links between selected aspects of care delivery and particular outcomes will have to be established in more focused studies. For example, if continuity of care is shown to be a process variable which strongly predicts quality of life in controlled trials of various community services, then it makes sense to use continuity of care, which has potential to be collected from an administrative data base, as a proxy for outcome when studying systems reform. It can also be argued that studies of system impact are in their infancy and that understanding the link between structural change and individual consumer outcome requires better methods of system measurement. It may be that the appropriate questions have not yet been asked. A NIMH funded study of the effects of major system changes in Ohio found few direct relationships between service variables and client outcome (Roth et al., 1996). The predictors of outcome that showed the most promise were questions that were introduced by consumer groups: whether consumers think services meet their needs, whether they feel like a genuine part of the process and whether they feel they have enough contact when they need it.

There are a number of pressing research questions concerning systems reform and a paucity of Canadian studies which address them. The following illustrate just some of the possibilities:

• What do consumers define as the most important things they need to live successfully in community settings? What needs can be met through the service system? What needs require other kinds of approaches and what are they?
• What impact does regionalisation of services have upon quality and access?
• Do separate (i.e. restricted to serious mentally ill) capitation funding mechanisms facilitate the transfer of patients from provincial hospitals to local communities?
• What are the predictors of service needs (according to providers and users) that could be incorporated into prospective payment methods for inpatient and outpatient care?
• What is the relationship of population health indicators to the need for, and utilisation of psychiatric services?
• How do fiscal incentives compare with non-fiscal strategies for changing practice patterns and improving the quality of care?
• What is the impact of involving new constituencies (family, consumer) in the planning and governance of service delivery?
• What are the most cost-effective methods for training/re-skilling professional staff for community work?

Recommendation 5 Further research on the effectiveness of services and supports and the impact of system change needs to be mandated and funded.

8.3 Exchange of Research and Experiential Knowledge.

Research Summaries

Projects such as this can play a crucial role in the transfer of knowledge from the research literature to the field, a critical step in the utilisation process. There are serious limitations to the use of publications in scientific journals and presentations at scientific meeting as a means of influencing policy and practice (Backer, Liberman and Kuehnel, 1986). They are read by small audiences and are usually oriented to other researchers rather than to practitioners or policy makers. Summaries which collate and appraise this literature and translate it into implications for policy and programs are more likely to facilitate use. There is also real value to descriptions of applications which demonstrate feasibility. A study of mental health decision-makers' reactions to research reports (Weiss and Bucuvalas; 1980) concluded that they apply both a truth test and a utility test. Truth is judged by research quality and conformity to prior knowledge. Utility is judged by feasibility and the degree of challenge to current policy. These two criteria and the relevance of the topic determine the assessment of usefulness.

There are a number of similar Health Canada funded projects related to mental health that have particular relevance to system reform. Reports that summarize the state of our knowledge about such common disorders as depression (CMHA, 1995b) and anxiety (Health Canada, 1996a; 1996b) provide a valuable educational resource for the general public and for practitioners who want to keep up-to-date about clinical interventions. Theory and practice concerning the evaluation of schizophrenia programs are described in two reports prepared by Goering for Health Canada (1994;1996c) that include program applications. Descriptions of innovative court diversion programs in place across Canada provide useful examples and contacts for those who are struggling to meet similar needs (Health Canada, 1995a). A recent Health Canada funded report published by CMHA (Ristock and Grieger, 1996), addresses "the challenge of forging a network of health/mental health professionals, social service providers, educators, survivors of family violence, consumer groups, and policy makers" to respond to the particular needs of survivors of violence. Reports that discuss directions for reform of other health sectors such as primary care and long term care provide important information about the changing health care environment and broad context in which mental health reform is situated (Advisory Committee on Health Services, 1996; Health Canada, 1995b).

As was discussed in the introduction to the Literature Review (ANMH), there were many significant topics that could not be adequately dealt with in this review, but are deserving of similar attention.

• The interface between psychiatry and primary care is a growing policy concern that was only touched upon in this project.
• The unique mental health needs of special populations, e.g. children, elderly, ethno racial, homeless, etc., as well as those with less severe and chronic problems, and promising approaches to providing them with service are other examples.
• Interministerial and cross sector initiatives could be documented and appraised.
• The delivery of mental health services in geographically remote communities is a common issue and there is a wealth of Canadian experience that has not been summarized or shared.
• Implications of the health determinants model for mental health promotion and prevention requires further exploration.

Meeting and Forums

In addition to the publication and distribution of reports, there is real value in convening groups of people with common interests for discussion and problem-solving. Such forums not only disseminate scientific knowledge, they also encourage the sharing of experiential knowledge that may never be published but can enrich understanding and expand our range of options. It is important that policy makers across Canada have the opportunity to learn about recent research that is relevant to their concerns as in the recent fiscal policy workshop sponsored by the Mental Health Policy Research Group in Toronto. It is also valuable for research methods themselves to be the focus of deliberation, as occurred in a national workshop that followed preparation of a Health Canada report on quality of life measurement among persons with chronic illness (Health Canada, 1996d). Such activities are a valuable complement to other means of exchanging information and learning.

Recommendation 6 The exchange of research and experiential knowledge should be facilitated through commissioning research summaries and convening meetings focused on the topics identified.