Raise HOPE - Hāpai te Tū manako - Southern DHBThe High Level Service Pathway diagram below shows...

Stepped Care Action Plan 2016-2020 1

Raise HOPE - Hāpai te Tūmanako

MENTAL HEALTH & ADDICTION SERVICES

Stepped Care Action Plan

2016-2020


CONTENTS Executive Summary………………………………………………………………………………………… 2

Moving to Wellness

- Overview…………………………………………………………………………………… 3

- Developing the Action Plan……………………………………………………….. 3

- Roadmap for Change…………………………………………………………………. 3

- The Stepped Care Model…………………………………………………………… 4

- Where are we now?........................................................................ 5

- Where are we heading?.................................................................. 5

- Service Design……………………………………………………………………………. 7

- Addressing inequalities………………………………………………………………. 8

- Service Quality……………………………………………………………………………. 8

- Service Coverage by Location……………………………………………………… 9

- Interface with Health, Local Government and Social Services…….. 9

Action Plan

- Overview…………………………………………………………………………………….. 10

- Key Principles for Engagement……………………………………………………. 10

- Key Considerations for Implementation……………………………………… 10

- Implementation Infrastructure…………………………………………………… 11

- Stepped Care Goals and Change Priorities from now to 2020…….. 12

- Action Plan 2016-17, 2017-18, 2018-19, 2019-20………………………. 15

Appendices

- Documents reviewed for Action Plan development……………………. 28

EXECUTIVE SUMMARY This Action Plan outlines the key priorities and programme of work required to implement the Stepped Care Model for Mental

Health and Addiction Services in the Southern District over the next four years. Stepped Care is a whole of sector, systems and

population approach proven to improve outcomes for consumers, families and whānau. Implementation will be led by the Alliance

South Mental Health & Addiction Network.

Currently there is no planned or structured model of care for service delivery and systems design in the Southern District. Increasing

demand for services will mean that current models of care and services will become unsustainable and unable to provide a

consistently high level of access and quality to consumers and families and whānau. A whole of system approach is required - key

to success will be the ability of people to self-manage their care, early intervention, prevention, and community based care that

supports people in their local communities and out of hospital.

This Action Plan outlines the priorities for change and the schedule and sequencing of projects and key milestones over the next

four years. Included are the key considerations for implementation including the intended outcomes for consumers and families

and whānau, service and systems redesign, governance and leadership, and resourcing and capacity.

As this programme of work is rolled out, specific and more detailed project plans and business cases will be developed in

consultation with key stakeholders to implement specific projects. It will be an evolving process providing opportunities to review

and measure progress along the way and to consider any changes or amendments that need to be incorporated as implementation

progresses.


MOVING TO WELLNESS OVERVIEW

To improve the health and wellbeing of people using Mental Health and Addiction services, the Southern District Health Board

(SDHB) developed Hāpai te Tūmanako Raise HOPE Strategic Plan 2012 - 2015 focused on:

1. Intervening in targeted, effective ways across the life course

2. Locating support close to consumers and in communities

3. Preventing mental illness and addiction by intervening early

4. Constantly improving sector quality, capability, productivity and capacity

5. Working as one sector with a systems approach

This approach aligns with the New Zealand Health Strategy emphasis on wellness focused care, that is; people powered, closer to

home, offering value and high performance, coordinated through one team and smart systems.

DEVELOPING THE ACTION PLAN

The Hāpai te Tūmanako Raise HOPE vision for Stepped Care Mental Health and Addictions Services provided for a four-year

implementation period, across the district that included developing a model and action plan. To ensure sector views were taken

account of in development of this action plan, surveys, focus groups and a rapid improvement event (RIE) workshop were

undertaken. This ‘Stepped Care Action Plan’ brings together information gathered from these engagements to inform the key

actions for implementation of Stepped Care.

ROADMAP FOR CHANGE

The diagram below provides a high level roadmap for the development of Stepped Care; including completed and planned

activities.

Figure 1 Roadmap for Change


THE STEPPED CARE MODEL The Stepped Care approach is nationally and internationally acknowledged as an effective mental health and addiction service

model. Aspects of the approach are being used in parts of New Zealand and have been successfully implemented in a number of

health systems around the world. In New Zealand the approach is promoted and endorsed by the Ministry of Health, the Mental

Health Commission, Mental Health Foundation and Platform Trust.

Stepped Care is characterised by a tiered approach to service provision - intervening in the least intrusive way from self-care and

across primary, community and specialist services to get the best possible outcomes for consumers and families and whānau.

Interventions have the best chance of achieving positive outcomes with the least intrusive manner and are regularly reviewed and

stepped up or down as needed. Crucial to the models success are the processes that support and manage a consumer’s transition

between the different steps of support and treatment. The model is designed to ensure that people have access to ‘the right

service, at the right time in the right place’.

The Stepped Care model for Southern DHB Mental Health and Addiction services identifies five steps of service delivery.

Interventions are delivered at each step with differing levels of intensity to meet the different needs of every consumer. Services

intervene early to help avoid the need for more intensive interventions. Services use the least intrusive support and/or treatment

required to meet the presenting need and have clearly defined thresholds to decide who should access support at each step.

People are encouraged to manage their own health and wellbeing at any step if they are well enough to do so. A key role of mental

health and addiction services is to coach and empower people to grow this ability. Under the stepped care model any door is the

right door - regardless of where or how people contact services they will be connected with the right service to support them.

People can start anywhere in the model and some people may need multiple steps of care at the same time, if these are addressing

different mental health and addiction issues. Should their situation change, clearly defined referral processes and pathways will

ensure that they move seamlessly between different steps of intervention should they need to, and how they exit services.

Figure 2 Stepped Care Model

The inverted pyramid (figure 2 above) illustrates how the model is structured. At each step services are matched to the specific

needs of every consumer and family and whānau.

Step 1 services include a broad range of informal and formal community supports and resources available to the population at

any time. Most people in the community do not require services or are able to self-manage their condition by accessing the

information and support they need.


Step 2 services are delivered in primary health and community settings and support people who are experiencing a mild mental

health and/or alcohol and drug condition. This is where most people already receive the advice, care and treatment they need to

stay well.

Step 3 services are delivered in primary and community settings to support people who are experiencing moderate to severe

mental health and/or alcohol and drug conditions. Step 3 services include child and youth and adult services, Maori services,

needs assessment and service coordination, community support, activity and vocational services and family/whānau services.

Step 4 services are delivered in hospital and community settings to support people who are experiencing severe mental health

and/or alcohol and drug conditions. Step 4 services also include community based residential services and crisis respite that

support people who live independently in the community with longer-term and enduring conditions.

Step 5 services are delivered to people with severe mental health and/or alcohol and drug problems experiencing acute and/or

complex problems. Emergency and after-hour services are available to people in crisis, and inpatient services for people who

require short-term hospital based support and treatment.

WHERE WE ARE NOW?

The following features provide a high level description of the sector:

Descriptors of service need have been primarily discipline-based (e.g. mental health, addiction) and level of care based

(e.g. inpatient, outpatient, community). This mix has informed service, workforce developments and standards.

Increasing specialisation of the workforce and development of occupational scopes of practice has occurred in general

mental health, forensic, addictions, children, youth and family, Maori Health, and interventions such as suicide prevention

in high-risk groups.

We have moved toward more community-focused care; constrained to some extent by funding and practices. A mix of

regulated and unregulated workforces and not for profit services have supported many of these developments.

Some recognition of consumers, family and whanau in an advocacy capacity and as carers.

Some recognition of the need for more culturally appropriate models for assessment and care for Maori, along with

Pacifica and other cultures.

Most people involved, in receiving or delivering services that provided feedback during the Stepped Care consultation process

agree that many of these changes have resulted in areas of very good service provision, with excellent practitioners and teams and

better outcomes. However, they also identify the creation of barriers to achieving more preventive, user-centered, wellness-

focused Stepped Care services.

In particular, existing services are described as:

Not always being provided in ways and/or environments that are culturally appropriate and conducive to inclusion and

wellness.

Fragmented, with entry barriers that limit practitioners/providers ability to refer and consumer’s access to what they

need when it’s needed.

Focused more on Illness, than wellness.

Health service structure and discipline driven rather than user centered.

Mostly, delivered through traditional health practitioner’s models, with a focus on collaboration between practitioners,

providers, family, whanau and their wider communities.

Sometimes exclusive of whanau and family.

Defined by legislative frameworks focused on quality and safety, which can promote established systems and practices

and concerns about risk.

Constrained by existing resource commitments and funding models, that create barriers to accessing care or treatment

at the right level, time and place.

WHERE ARE WE HEADING? Most people involved, in receiving or delivering services that provided feedback; preferred a community orientated Stepped Care

service environment where:

A consumer/whanau/family centered, wellness-focus is taken in a wider social context.

Provision happens early in ways and environments that are destigmatized.


Consumers, whanau and providers/practitioners collaborate as one team (whatever the location or discipline) to ensure

joined up coordinated services.

Practice cultures, structures and funding:

o Are responsive to growing demands and reduce barriers to care.

o Encourage people to own and manage their wellness, through self-help and more consumer led activity.

o Are culturally appropriate.

o Enable early intervention at an appropriate level.

o Include family, and whanau in the process of recovery.

o Agree in-common screening, assessment protocols and care pathways, reducing repetitive telling of the consumer’s

story.

o Provide for a consumer information portal, where there is sharing of one single agreed record of care.

o Minimise waiting and focus on discharge planning from the start.

The High Level Service Pathway diagram below shows what the service pathways might look like in a Stepped Care environment;

where the service arrangements and practices enable access to user centered care or treatment, at the right level, time and place.

Figure 3 Stepped Care Future State: High Level Service User Pathway

In line with a Stepped Care approach shown:

Consumers and their family and whanau can enter at any point and have access to the level and mix of services needed

at the right time and place.

The mental health and addiction workforce, consumers, family, whanau and wider communities of practice work together

to deliver the outcomes shown at the right hand side, with wellness teams available in easily accessible community based

hubs.

For this to be achieved we need to invest in community and primary care capability to:

Ensure that consumers are actively engaged in informing and shaping sector wide developments. There has been a very

clear message from consumers of “nothing about us without us”. This philosophy is key to development and delivery of

Stepped Care.

Develop higher-skilled support, peer and generalist mental health and addictions workforce in the community and primary

care service sectors.

Build across-sector provider relationships and collaboration across communities of practice.

Ensure early and lowest level intervention to improve outcomes and reduce the current high demands on more intensive

community, hospital-based inpatient and specialist services.


For this to happen upfront investment, followed by a gradual shift in funding focus from inpatient to community/primary care is

also needed, at the same time as ensuring quality of existing services and managing risks. It will be important to build on what

works well, as new services and practices are developed. Achieving this will require a concerted effort in partnership with all

involved.

SERVICE DESIGN

To implement the integrated system of care concept shown above, a Stepped Care service design is needed to assess current

service arrangements and gaps and to plan for service development, in a way that ensures a managed transition of services to an

integrated system of care across the district.

The principles for Stepped Care service design come from the Hāpai te Tūmanako Raise HOPE Stepped Care vision (people,

environment, leadership, services, workforce) and from the information gathered through the rapid improvement event (RIE),

survey and focus groups.

Services in the Stepped Care Model will be responsible for:

People

Services and practitioners are focused on wellness, working with consumers, whanau, family and their wider communities.

Differing community and cultural needs and expectations are understood, acknowledged and respected.

Environment

Service environments, cultures, facilities and practices that support recovery and wellness.

Mutual recognition, collaboration and respect exist between consumers and providers at all times.

Services are accessible in or close to home, and mostly in the community.

Leadership People, seeking services are fully informed, with a goal of establishing a partnership with providers to develop evidence

based wellness plans in the least intrusive and lowest level of service intensity.

Service delivery is joined up. People using the services, their whanau or family, and highly coordinated practitioners,

collaborate as one team, wherever they're located, whatever their skill set.

Services

Any entry point to services is the ‘right door’. Movement between different levels of service intensity is determined

according to changing needs and is coordinated and seamless.

Shared people-centered pathways are in use for Stepped Care coordination, screening, assessment and referral, up and

down the model.

Online shared in-common recording of care (wellness plan). Consumers are integral in preparing information about their

care.

Shared access to a common information platform. Consumers are consulted in the development of mental health,

addictions, support and advocacy content.

Service funding follows the consumer and is responsive to changing population demands, practice requirements and

related service expectations over time. For example, packages of care are developed and funded, based on the

assessment of the presenting concerns, and likely levels of care needed.

Workforce

A mix of high-skilled generalist mental health and addictions practitioners, first line support and peer workers will be

developed; supported by access to more specialist practitioners where needed.

Flexible workforce, experienced in evidence based practices across a range of service needs, including:

o Working collaboratively with the consumer, family, whanau, and other workers and disciplines as partners

focused on wellness.

o Consumer-centric care planning, levels or care and information sharing.

o Working in homes or using mobile or online contact with consumers, where distance or urgency precludes face-

to-face contact.

Highly developed interpersonal skills with commitment to on-going development, including:

o Regular across-sector skills development.

o Appropriate supervision that meets industry and/or practice standards.

o Ongoing participation in user and provider continuous quality improvement processes.


ADDRESSING INEQUALITIES

Southern DHB strategic plan 20151 notes that “Māori and Pacific people living in Southern experience significant health

inequalities” and has committed to reducing these by “improving access to services, and directing resources to the populations

and patients with the greatest health and support needs”. The following actions will be incorporated into all service design,

planning, purchasing and delivery.

1. Use of the Health Equity Assessment Tool (HEAT), a planning tool that improves the ability of mainstream health policies,

programmes and services to promote health equity. HEAT will be used during detailed planning for Stepped Care

implementation.

2. Setting specific targets and key performance indicators for improving health system performance for Māori and Pacific

people.

3. Enhancing the intended role of Māori health service providers within the Southern health system and locality networks,

and their relationship with mainstream providers.

4. Building the Southern health system’s cultural competence, recognising that the majority of Māori and Pacific people

receive most of their care from mainstream services.

5. Including measures that assess the effectiveness of services for Māori and Pacific people.

6. Lifting the participation of Māori and Pacific people within the health workforce.

7. Continuing to ensure Māori leadership and engagement is reflected within all levels of decision-making ensuring that

whānau ora is incorporated as a core component of the population health approach.

8. Collaboration of Southern DHB and WellSouth in developing plans for Māori Health and for Pacific Health, linked with

the priorities presented in this Action Plan.

SERVICE QUALITY

To achieve the people centered practices required, all Stepped Care services will adopt a continuous service quality improvement process, inclusive of different practice standards, such as shown in the figure below.

Figure 4 Continuous Improvement Approach to Stepped Care

1 SDHB Strategic Plan Piki te ora 2015, page 29


SERVICE COVERAGE BY LOCATION The implementation schedule outlined in this plan is taking a locality based approach. This approach will see Stepped Care

implemented in smaller geographic areas and populations in the district which will ensure that detailed analysis, planning and

actions support the implementation of the model. It also recognizes that implementing Stepped Care is not a one-size fits all

approach - different localities, service types and populations will have their own unique issues that will require locally developed

and tailored solutions. This approach is complimented by the district-wide priorities and activity detailed in this action plan.

The Mental Health and Addiction Network and its Design Groups will continue to work on identifying and addressing issues

including access to services, service needs and develop detailed location information, as part of service design in consultation with

the sector. While new service arrangements will be needed in some locations, it is foreseeable that many existing services can be

redeveloped and redesigned as stepped care providers, or work in partnership with others to deliver Stepped Care services.

INTERFACE WITH HEALTH, LOCAL GOVERNMENT AND SOCIAL SERVICES

Connections between health, public health prevention, local government, education, corrections, housing, and other social

services to improve key determinants of health and wellbeing are an important part of Stepped Care. Potential partnerships will

be considered in all future planning, service redesign and in all project work streams. Co-location, visiting and/or virtual

arrangements with services, such as; Maori health, older persons health, public health, child, adolescent and family services, and

alcohol and drug services, will be important to improve the early interventions and integration of service delivery across complex

consumer needs. This approach would also benefit treatment of co-existing or chronic and long-term concerns, such as eating

disorders, chronic pulmonary disorders and diabetes.


ACTION PLAN

OVERVIEW

Raise Hope is an ambitious strategy. It asks individuals and agencies within the mental health and addiction sector to change the

way they work. Though the benefits of Stepped Care are accepted by most there are significant gaps and barriers to overcome.

The shift to Stepped Care requires significant changes to the shape of services, and in sector culture and practices. An integrated,

coordinated approach is needed that includes:

An agreed and clear picture of the new Stepped Care future.

Sponsorship of the plan at the level needed for sector wide change.

A supporting Business Case to secure the dedicated funding, on-going senior level sponsorship, and to demonstrate

commitment to stakeholders.

Defined work-streams to drive implementation, with:

o Key milestones, activities and success measures.

o Investment decisions points and estimates of resource requirements.

o Opportunity and risk analysis with actions for mitigation.

o Assurance and oversight processes, including sector representation.

o Stakeholder assessment, communications and engagement activities.

Ongoing engagement within the Alliance South framework and with other key stakeholders, effective change strategies, sector

participation and buy-in, will be needed for the successful implementation of Stepped Care.

KEY PRINCIPLES FOR ENGAGEMENT Ensure all aspects of implementation and work streams are influenced and informed by equitable consumer and family

participation and choices; in partnership with all population, general and specialist mental health and addictions

practitioners/teams in hospital, community and primary care settings.

Ensure actions to address inequalities are considered and embedded, as apart of all work-stream outputs.

Create and maintain a transparent process for all participants.

Share information and follow the processes committed to.

Engage in constructive problem solving and create opportunities for solution-focused outcomes.

Build in opportunity to reflect, adjust and renew.

Persevere in the face of challenges to change.

Own moments that don’t live up to aspirations resolve and move forward positively.

KEY CONSIDERATIONS FOR IMPLEMENTATION Feedback received during consultation with the sector identified the following six key themes to be considered and addressed

throughout the Stepped Care implementation process.

Service Design

Service design for the Stepped Care Model will require alignment with SDHB policies and Ministry of Health requirements. It will

have significant influence on quality standards, training and people aspects of the implementation. Ongoing input will be included

from consumers, whanau, family, public, Maori providers and other sector providers and unions as different stages of service

change and redesign is planned and implemented.

Procurement (Service Planning and Purchasing)

Service providers will need time to develop their capability to deliver Stepped Care services and take on new service contracts. A

more collaborative approach to planning and purchasing will build relationships and achieve the changes sought, while ensuring

sustainability of services.


People and Practice

Consultation will be required regarding service, protocol, systems and practice changes. Early respectful communications, with

sector input from consumers, whanau, family, public, Maori providers and other sector providers, practitioners and unions, is

critical for a smooth transition. Consideration of potential changes to service placement and/or location of employment will occur,

planned for across the sector with all participate groups.

Capability and Training

The development of a ‘top-of-scope’ framework that will provide the foundation for designing training programmes. It will also

enable consumers, whanau, family, public, Maori providers and other sector providers, practitioners to better understand each

other's capability, and to plan workforce development. The framework may also support the development of new procurement

arrangements, outlining targeted capability as part of provider assessment criteria for Stepped Care, accreditation, contracts and

monitoring.

Process and Standards

Identified as a priority is the development of common screening and assessment processes, referral protocols and standards that

meet different presenting needs. Sector experts including consumer, family, whanau, Maori providers and other providers and

practitioners in mental health and addictions, will need to be actively engaged in developing and supporting the practice. The

acceptance of these is essential for:

Developing the confidence, trust and respect needed for collaborative working behaviours.

Appropriate tailoring of processes and standards to consumer needs, including culturally appropriate processes and

assessment.

Effective monitoring and maintenance of service quality and appropriate risk management practices.

System Design

Systems are required for accurate recording, storage and access to information between providers. There are a number of national

and regional initiatives focused on improving health information infrastructure and access to national web-based online and

telephone mental health guidance and support. The Stepped Care implementation process will maintain an accurate picture of

when these initiatives will deliver, and ensure Stepped Care requirements are connected into national programmes.

IMPLEMENTATION INFRASTRUCTURE The governance structure will coordinate and manage the implementation of the Stepped Care Model. This builds on the existing

infrastructure of Alliance South and the Mental Health & Addictions Network. The Alliance Leadership Team will continue to

provide oversight, advice and leadership to the Network. This function is supported by the Alliance Management Team which

brings together senior managers and clinicians from across a range of health specialties providing valuable input and advice

regarding the work of the Network.

The Mental Health and Addictions Network will lead the implementation of the Stepped Care Model with fit-for-purpose work

streams established to implement specific projects including the Locality Based Implementation Sites, Workforce Development

and Systems and Quality redesign. Also supporting this process will be the established locality Networks in Dunedin, Southland,

Waitaki and Central-Lakes.


Figure 5 Stepped Care Implementation Infrastructure

STEPPED CARE GOALS AND CHANGE PRIORITIES FROM NOW TO 2020

STEP 1

Self Care and Informal Community Responses

GOALS

More people have improved health literacy including an awareness of services, and understanding of mental health and

addiction issues.

More people have the information and resources they need to take care of their own wellbeing.

Increased awareness about suicide and improved ability to identify and support people at risk of suicide.

More people engage with self-help and support groups.

More people access self-help information, resources and e-therapy in the community and on-line.

Communities are resilient with less stigmatisation and discrimination.

PRIORITIES FOR ACTION

A joined up, coordinated approach to develop and implement population health and health promotion initiatives and

campaigns between local providers and regional and national agencies.

A holistic approach that addresses the wider determinants of health (employment, housing, education).

A focus on reducing inequities in the health system especially for Maori and marginalised, at-risk individuals and groups

in the community.

Implementation of the Southern District Suicide Prevention Action Plan 2015-2018.

Promotion and coordination of local support and advocacy groups that support individuals and families and whanau.

Promote local and national services including 0800 helplines and on line e-therapies and resources.


STEP 2

Primary Health Services

GOALS

More people receive their care in community settings living independent, socially inclusive lives.

More people experience improved and timely access to services and greater flexibility regarding their care.

Services are fully integrated - providing a coordinated and holistic response to consumers, families and whānau and

people are provided with the information they need to connect them with the right service.

Services are outcome focussed - working in partnership with individuals to enhance wellness and achieve the best

outcomes for them.

More people have the information and resources they need to take care of their own wellbeing (self-management).


Develop and implement a targeted programme of mental health and addiction education and training for the primary

health workforce.

Establish relationships with specialist mental health and addiction services to provide clinical support and ongoing

professional development and peer support.

Implement new mental health and addiction Health Pathways for use by General Practice Teams that support and

enhance diagnosis, treatment and referral options for consumers and families and whanau.

STEP 3

Primary Mental Health & Addiction Services & Specialist Community Services

GOALS

Services and systems are fully integrated - providing a coordinated and holistic response to the needs of individuals and

families and whānau.

More people receive their care in community settings living independent, socially inclusive lives.

More people experience improved and timely access to services and greater flexibility regarding their care.

More people have the information and resources they need to take care of their own wellbeing.

Services are outcome focussed - working in partnership with individuals to enhance wellness and achieve the best

outcomes for them.

Fewer people require higher intensity interventions and fewer re-present to mental health and/or addiction services.


Reorient and redesign services and models of care to ensure they are flexible and can be delivered in community and

primary settings.

Have in place early and brief intervention services and ensure that they are easy to access.

Establish and enhance peer support services.

Implement systems and protocols that ensure service delivery is integrated and connected.

Upskill the workforce to ensure they are working at the top of their scope.

STEP 4

Specialist and Long-Term Services

GOALS

Services are fully integrated - providing a coordinated and holistic response to the needs of individuals and families and

whānau.


Services are outcome focussed - working in partnership with individuals to achieve the best outcomes for them.

More people receive their care in the community, living independent, socially inclusive lives.



Reorient and redesign services to ensure they are flexible and can be delivered in community settings.

Establish and enhance peer support services.


Support and enable the workforce to ensure they are working at the top of their scope.

STEP 5

Specialist Acute and/or services for highly acute complex needs

GOALS


Services are fully integrated - providing a coordinated and holistic response to the needs of individuals and families and

whānau.

Services are outcome focussed - working in partnership with individuals to achieve the best outcomes for them.

More people receive their care in the community living independent, socially inclusive lives.


Establish community based and peer-led rehabilitation services.


Deliver health interventions that are evidence based and recognised as best practice.

Upskill the workforce to ensure they are working at the top of their scope.


STEPPED CARE ACTION PLAN

2016-2017 Summary of 2016-17 milestones:

Establishment of the Stepped Care Locality Based Development Sites in the Clutha District (all mental health and addiction services) and Southland District (all child,

youth and adolescent mental health and addiction services), and the development of local service delivery models and implementation.

Review of all Mental Health and Addiction Needs Assessment and Service Coordination services.

Mental health and addiction information included as part of a new Southern-wide health website (HealthInfo).

Develop new Health Pathways to be used in Primary Health settings to support improved diagnosis, treatment and referral pathways.

Youth Brief Intervention Service Model confirmed.

New service model developed for Activity and Vocational Services and service provider(s) confirmed.

New district-wide peer support service established.

Service & Systems Redesign Priorities

Actions

Responsible/Partners

Timeframe

Loca

lity

Base

d A

ppro

ach

Clutha District - All Mental Health and Addiction services: Establish a Design Group to develop a localised, fit-for-purpose service

model in the Clutha District that aligns with the principles of Stepped Care and that will support the wider implementation of the Stepped Care Model across the Southern District. All mental health and addiction services are in-scope.

- Establish Design Group including Terms of Reference and membership

- Complete service stock-take

- Develop local Stepped Care Model and produce an Action Plan.

- Complete any proposals required for investment including local service and systems redesign

Mental Health & Addiction Network

Design Group

Design Group

Design Group

November 2016

December 2016

March 2017

March 2017


Southland - Child and Youth Mental Health and Addiction services: Establish a Design Group to develop a localised, fit-for-purpose service

model in the Southland District that aligns with the principles of Stepped Care and that will support the wider implementation of the Stepped Care Model across the Southern District. All child and youth mental health and addiction services will be in-scope.


- Complete service stock-take.

- Develop local Stepped Care model and produce an Action Plan.



Design Group

Design Group

Design Group

November 2016

December 2016

March 2017

March 2017

NA

SC

Needs Assessment & Service Coordination (NASC):

Complete a comprehensive review of all Mental Health and Addiction NASC Services to evaluate how fit-for-purpose they are in the Stepped Care Model. Findings of the review will confirm if any re-modelling of NASC services is required and any potential Business Case and procurement process.

- Updated model and business case completed if required

- Procurement process completed if required

- Delivery of new service model

Planning & Funding

April 2017

August 2017

December 2017

STEP

1

Mental Health & Addiction Website (HealthInfo) Develop a single source of truth/centralised resource with up-to-date

information about services, mental health and addiction disorders, service pathways or other useful links and information.

HealthInfo will provide an improved communication tool for consumers, families, service providers and the general public. Provides a pathway into services and promotes the Stepped Care view of one-system, one-service.

Public Health/Health Promotion Services Public health service coordinate their planning and programme delivery

with one another and with national providers to ensure a coordinated, collaborative approach, best practice, the best use of resources and a cohesive/consistent message to the community.

- Develop business case in consultation with stakeholders

- Confirm website content and functionality

- HealthInfo goes live - implement marketing/ communications strategy

- Services complete a joint annual planning process and develop a shared action plan (including the Southland District Suicide Prevention Action Plan 2015-18)


Alliance South

Service Providers

Public Health Services (local and national)

June 2017

June 2017


STEP

2

Health Pathways Implement mental health and addiction Health Pathways that will

enable Primary Health Care providers to better engage and support consumers, families and whānau and is a vital step in successfully implementing the Stepped Care Model.

Locality Based Stepped Care Implementation: Step 2 service providers will be involved in the two locality based

Stepped Care implementation projects in the Clutha District and Southland District. The level of input and engagement to be confirmed as the projects progress.

- Work with Primary Health providers to develop and implement Health Pathways

- Locality Based Design Groups engage/consult with services to support their implementation objectives


Health Pathways Team

Mental Health & Addiction Network & Design Groups

June 2017

June 2017

STEP

3

Brief Intervention Services - Youth A review of Youth Primary Mental Health Services - Brief Intervention

(12-19 years) completed in June 2016 identified gaps and inequities in the current system and barriers to young people accessing services. A proposal is being developed to address these issues with a proposal to establish a ‘district-wide’ service model.

Community Based Activity and Vocational Services Develop an updated service model for community based activity and

vocational services. It will include a priority to increase employment opportunities for consumers. This is a Ministry of Health requirement and is identified as a priority project in Hāpai te Tūmanako Raise HOPE and the Southern DHB Annual Plan 2016-17.

NOTE: While this is identified as a Step 3 service, activity and vocational services can, and do support people at every step of the Stepped Care Model.

District-Wide Peer Support Service: Peer support is identified as a service priority for all DHB’s in Rising to

the Challenge (MoH) and as a gap and priority in Hāpai te Tūmanako - Raise HOPE Mental Health and Addictions Southern Strategic Plan.

There is currently under-investment in the Southern District with peer support only available in Dunedin with some outreach in South/North Otago.

NOTE: While this is identified as a Step 3 service, peer support services can, and do support people at every step of the Stepped Care Model.

- Complete business case and initiate procurement process

- Confirm provider(s)

- Start new service

- Complete review and develop new service model


- Procurement completed

- Start of redesigned/new service




Planning & Funding

Planning & Funding


Service Providers

Planning & Funding


Service Providers

February 2017

June 2017

October 2017

March 2017

June 2017

September 2017

December 2017

January 2017

March 2017

By June 2017


Locality Based Stepped Care Implementation: Step 3 service providers will be involved in the locality based Stepped

Care implementation projects in the Clutha District and Southland District. The level of input and engagement to be confirmed as the projects progress.



June 2017

STEP

4 Locality Based Stepped Care Implementation

Step 4 service providers will be involved in the two locality based Stepped Care implementation projects in the Clutha District and Southland District. The level of input and engagement to be confirmed as the projects progress.



June 2017

STEP

5

Community Based Adult Rehabilitation Services: Develop a new community based service to support people (adults) with

high/complex and long term mental health needs. The service will provide safe, timely and effective support to people whose needs cannot be met by less intensive mainstream adult mental health services and who would otherwise be long-term users of inpatient services.

- Business case sign off

- Consultation with stakeholders

- Procurement process



Planning & Funding


Service Providers

February 2017

April 2017

August 2017

October 2017

February 2018



Establishment of a Stepped Care Locality Based Development Site in Dunedin (all mental health and addiction services) and the development of a local service delivery

model and implementation.

New funding for six Peer Support Work training places.


New community-based peer-led crisis respite service established.

Review all Mental Health and Addiction Inpatient Services.

New community-based adult rehabilitation service established.


Actions


Timeframe

Wor

kfor

ce

Dev

elop

men

t

Peer Support Workforce: The Alliance South Mental Health and Addictions Workforce

Development Action Plan 2016-2019 has identified the need to grow the capacity of the peer support workforce. It proposes to do this by making six peer support training places available each year from 2017-18.

- Expressions of Interest process completed

- Applicants confirmed, training begins

- Project reviewed after year 1

Planning & Funding


Workforce Leadership Group

August 2017

January 2018

June 2018

Loca

lity

Base

d A

ppro

ach

Dunedin - all mental health and addiction services: Establish a Design Group to develop a localised, fit-for-purpose service

model in Dunedin that aligns with the principles of Stepped Care and that will support the wider implementation of the Stepped Care Model across the Southern District. All mental health and addiction services will be in-scope.


- Complete service stock-take and develop local Stepped Care model

- Produce Action Plan


Mental Health & Addictions Network

Design Group

Design Group

Design Group

July 2017

September 2017

December 2017

December 2017


STEP

1 Public Health/Health Promotion Services:

Step 1 service providers will be involved in the locality based Stepped Care implementation projects. The level of input and engagement to be confirmed as the projects progress.



June 2018 ST

EP 2

Health Pathways

Implement mental health and addiction Health Pathways that enable Primary Health Care providers to engage and support consumers, families and whānau and that supports the implementation of the Stepped Care Model.


Care implementation projects. The level of input and engagement to be confirmed as the projects progress.

- Continue to work with Primary Health providers to develop and implement Health Pathways


Mental Health & Addiction Network and Health Pathways Team


June 2018

June 2018

STEP

3

Locality Based Stepped Care Implementation:




June 2018

STEP

4

Community Based Peer-Led Crisis-Respite Services: Currently there are no peer-led crisis respite services funded or

delivered in the Southern District. The new service will be based in Dunedin and will consist of a four/five

bed residential facility. The service will provide: o Active support for people in the community, preventing the

need for hospitalisation o A homelike, safe and supportive environment o Recovery focused support and interventions in collaboration

with clinical services o Staff who work alongside clients to enhance wellness, reduce

stress/distress and maintain their safety in the community o Peer and family/whānau support

The service will provide recovery orientated support, designed to be individually tailored and responsive to the individuals changing needs. It is a peer-led service, run by people who have a lived experience of mental illness.

- Service model developed

- Procurement process completed

- Start of new service

Planning & Funding


Service Providers

September 2017

December 2017

March 2018






June 2018

STEP

5

Review of Inpatient Mental Health Services As the Stepped Care model is implemented and specific redesign

projects to services and systems are completed - it is anticipated that one of the outcomes may be reduced demand for inpatient services.

Projected savings achieved from any changes to inpatient services will be re-invested into other services and projects identified as priorities in the Stepped Care Implementation Plan and by the Mental Health & Addictions Network.

- Review findings and recommendations agreed

- Service redesign and timeframes confirmed with provider(s)

- Service reconfiguration implemented

Planning & Funding

Independent reviewer

October 2017

December 2017

June 2018



Establishment of a Stepped Care Locality Based Development Site in Southland (all mental health and addiction services) and the development of a local service delivery

model and implementation.

Creation of a new Education and Training HUB and dedicated workforce development roles.


New service model developed for Adult Alcohol and Drug Services and service provider(s) confirmed.


Actions


Timeframe

Wor

kfor

ce

Dev

elop

men

t

Workforce Development: The Alliance South Mental Health and Addictions Workforce

Development Action Plan 2016-2019 has prioritised the need for additional resources to implement the plan. This consists of two new FTE roles which will make up a new Education and Training HUB to coordinate, promote and implement workforce development priorities and actions outlined in the plan.

- Service model developed

- Procurement process completed

- Start of new service

Planning & Funding


Workforce Leadership Group

September 2018

November 2018

December 2018

Loca

lity

Base

d A

ppro

ach Southland - all mental health and addiction services:

Design Group (including Terms of Reference) to be confirmed to begin the development of a localised, fit-for-purpose service model in the Southland District that aligns with the principles of Stepped Care and that will support the wider implementation of the Stepped Care Model across the Southern District. All mental health and addiction services will be in-scope.



- Produce an Action Plan



Design Group

Design Group

Design Group

July 2018

September 2018

December 2018

December 2018


STEP





June 2019

STEP

2

Health Pathways Implement mental health and addiction Health Pathways that enable

Primary Health Care providers to better engage and support consumers, families and whānau and that supports the implementation of the Stepped Care Model.







June 2019

June 2019

STEP

3

Community Based Adult Alcohol and Drug Services: Develop a new community based service model will produce improved

efficiencies and better value for money. A new district-wide community based adult Alcohol and Drug service

model will provide: o Community based and outreach services o Community detox service o Recovery focused support and interventions o Culturally appropriate services o Expanded peer support and support worker roles



- Review current service provision

- Develop new service model in consultation with stakeholders






Service Providers

Planning and Funding


By July 2019

June 2019

STEP

4





June 2019


STEP

5



- Locality Based Design Groups engage/ consult with services to support their implementation objectives


June 2019



Establishment of a Stepped Care Locality Based Development Sites in the Waitaki District and Central-Lakes (all mental health and addiction services) and the

development of local service delivery models and implementation.


Complete an evaluation of the Stepped Care implementation process.


Actions


Timeframe

Loca

lity

Base

d A

ppro

ach

Waitaki - all mental health and addiction services: Design Group (including Terms of Reference) to be confirmed to begin

the development of a localised, fit-for-purpose service model in the Waitaki District that aligns with the principles of Stepped Care and that will support the wider implementation of the Stepped Care Model across the Southern District. All mental health and addiction services will be in-scope.






Design Group

Design Group

Design Group

July 2019

September 2019

December 2019

December 2019

Central-Lakes - all mental health and addiction services: Design Group (including Terms of Reference) to be confirmed to begin

the development of a localised, fit-for-purpose service model in Central-Lakes that aligns with the principles of Stepped Care and that will support the wider implementation of the Stepped Care Model across the Southern District. All mental health and addiction services will be in-scope.






Design Group

Design Group

Design Group

July 2019

September 2019

December 2019

December 2019


STEP





June 2020 ST

EP 2

Health Pathways Implement mental health and addiction Health Pathways that enable

Primary Health Care providers to better engage and support consumers, families and whānau and that supports the implementation of the Stepped Care Model.







June 2020

June 2020

STEP

3

Locality Based Stepped Care Implementation:




June 2020

STEP

4





June 2020

STEP

5





June 2020

EVA

LUA

TIO

N

Evaluation The Network will engage with an external evaluator to complete a

comprehensive evaluation of the Stepped Care Model Implementation process and outcomes. Learnings will inform future planning.

- Evaluation findings and recommendations confirmed

- Information supports and informs the development of strategic and annual planning processes


External evaluator

June 2020


APPENDIX DOCUMENTS REVIEWED FOR IMPLEMENTATION PLAN DEVELOPMENT

Number Title

1 Blueprint II

Improving mental health and wellbeing for all New Zealanders, How things need to be

Mental Health Commission, June 2012

2 New Zealand Health Strategy

Future Direction, 2016

3 New Zealand Health Strategy

Roadmap of Actions, 2016

4 Raise Hope - Hāpai te Tūmanako Strategic Plan

The Southern DHB Mental Health and Addiction Strategic Plan 2012-2015

5 Raise Hope - Hāpai te Tūmanako, Background Paper

Supporting the Southern DHB Mental Health and Addiction Strategic Plan 2012-2015

6 Hāpai te Tūmanako - Raise HOPE Stepped Care Model

The Southern Stepped Care Model, December 2015

7 Hāpai te Tūmanako -

Raise HOPE Implementation Plan 2015-2020

(Draft Versions) November 2015

8 Project Plan, Hāpai te Tūmanako - Raise HOPE

Development and implementation of a sector-wide Stepped Care Model


5 February 2015

9 Implementation Plan for Hāpai te Tūmanako - Raise HOPE Strategy

10 Rapid Situational Analysis:

Knowing The Communities, Resources and Context for Mental Health and Addiction Planning & Funding in the Southern DHB Region, October 2011

11 Future Direction, The Southland Mental Health and Addictions Network

Southland Mental Health and Addictions Service Map and Directory 2014-2015

12 A District Network Model for the Mental Health and Addictions Sector

September, 2014

13 Co-creation Sector Survey Reports 18 April 2016 (RIE and Wider Sector)

14 Focus Group Feedback; Groups Dunedin, Oamaru, Invercargill Consumers, Providers and Health Practitioners - Queenstown services providers and practitioners

15 Rapid Improvement Event Outputs Report 29 April 2016

16 Queenstown Council Long term Plan 2013

17 Statistics New Zealand Population Statistics 2011 - 2031

18 Southern District Health Board Strategic Plan 2015

19 Local Government New Zealand Boundary Maps

20 The Esteem Team- coordinated care in the Sandwell Integrated Primary Care Mental Health and Wellbeing Services - Kings Fund 2013 UK

21 Ministry of Health NZ

A guide to effective consumer participation in Mental Health Guidelines

Raise HOPE - Hāpai te Tū manako - Southern DHBThe High Level Service Pathway diagram below shows...

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