Implementing recovery-oriented practice in older people’s mental health services: the NSW experience

Abstract

Personal recovery is central to Australian mental health standards, but promoting recovery-oriented practice remains a wicked problem (ie complex, with definitions and appropriate interventions impacted upon by context and values), with limited evidence regarding effective implementation. This case study re-examines a statewide initiative to enhance recovery-oriented practice in older people’s mental health services in New South Wales from the perspective of complex adaptive systems. The initiative consisted of three key strategies: (1) statewide collaborative leadership and practice resources; (2) locally determined and led improvement projects; and (3) evaluating, disseminating and sustaining initiative outcomes. Published outcomes of the initiative, related policy and benchmarking materials and author reflections are used to propose lessons for other services and policy makers. From a systems perspective, a relatively small investment from a state policy unit to enhance a facilitating environment resulted in the emergence of local leaders and voluntary participation of services within 80% of local health districts without funding incentives. Local leaders and activities informed statewide policies and models of care to sustain practice change. Limitations included variability in project scopes and the involvement of people with lived experience, as well as the level of refinement in change management approach. Self-audit and consumer-rated experience suggest resilience of practice and culture change. The outcomes are consistent with conceptualisations of mental health services being complex adaptive systems requiring distributive leadership. Established mechanisms encouraging statewide cooperation between clinicians, service managers and policy makers may have been significant facilitators of engagement in practice change. What is known about this topic? Recovery remains an important concept for older people with mental ill health, with implementation of recovery-oriented practice a wicked problem. What does this paper add? Central policy investment in a collaborative facilitatory environment can stimulate the emergence of local leadership and investment in actions to enhance recovery orientation. As predicted by complex adaptive systems theory, the impact of the leaders developed may be broader than the sum of individual project outcomes. What are the implications for practitioners? A start where you can message can engage and enable leaders in feasible and locally relevant changes consistent with a statewide strategy. This may be a feasible approach to improving recovery orientation in mental health care services for and beyond older people, with potential implications for addressing other wicked problems in health care.

What are the evidence bases for developing models of rehabilitation for older people with mental illness in Australia?

“…Supporting families and carers to help maintain a person’s identity over time is particularly important for people with dementia. Innovative methods for co-design with older people, 8 age-relevant peer work 9 and systemic changes of service orientation 10 are emerging. A statewide recovery-oriented practice project focused on older people with mental illness 11 identified strategies to support empowerment, agency and self-management as fundamental.…”

“…Supporting families and carers to help maintain a person's identity over time is particularly important for people with dementia. Innovative methods for co-design with older people, 8 agerelevant peer work 9 and systemic changes of service orientation 10 Mental health rehabilitation guidance specific to older people. The only relevant systematic review regarding mental health rehabilitation in older people concluded evidence was insufficient to make recommendations for an older population.…”

Comment on: What are the evidence bases for developing models of rehabilitation for older people with mental illness in Australia?

“…The concept of recovery is meant to be central for both adults under and over 65 years of age; however, previous research has indicated that healthcare workers are less likely to engage in recovery-orientated practice with OPMI. 5 Conversely, previous research has demonstrated that older people’s MHC services do not have recovery as the primary goal. 3 , 4 Koder 3 found that staff held poor attitudes towards recovery including a lack of hope for this cohort.…”