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Partners in Recovery: case study (systems perspective)

This case study provides an example of how Partners in Recovery (PIR) may work in practice to improve the way services across different sectors work together to improve consumer outcomes.

Partners in Recovery: case study (systems perspective) (PDF 129 KB)

This is a fictional example of how PIR may look in a region defined by specified demographics and the service provider system. Actual PIR models will be determined by the specific needs and characteristics of the relevant region.

Medicare Local Region A

Medicare Local Region A is a region with a residential population of approximately 500,000 people, spread across a geographical area of approximately 40,000 square kilometres. It is estimated that around 475 people residing within the region have a severe and persistent mental illness with complex needs, and are in the target group which the Partners in Recovery initiative aims to benefit.

A number of services used by people with severe and persistent mental illness with complex needs are delivered across the region. The State government mental health service provides crisis assessment, a range of clinical and therapeutic interventions, and residential recovery and rehabilitation programs. Two private psychologists and a private psychiatrist are available in the region. The State Health Department funds acute care, primary and allied health care and a range of tertiary health services. Low-cost, long-term housing is available through the State government housing program and there are three short to medium-term supported accommodation services across the region. There are two Personal Helpers and Mentors Service (PHaMS) sites, one Support for Day to Day Living in the Community (D2DL) service and three organisations delivering the Mental Health Nurse Incentive Program (MHNIP). There are fourteen Centrelink offices spread across the region and eight Family Assistance Offices. One residential rehabilitation service is available. A variety of support services are delivered through non-government organisations across the region such as emergency assistance, living skills programs, disability support services, and homelessness programs.Top of page

Medicare Local Region A 'Partners in Recovery Organisation'

The Medicare Local Region A PIR Organisation (PIRO) was set up within an existing and well established non-government organisation that provides a range of direct health and welfare support services to people with a mental illness.

Through the process of determining an effective PIR model in the region during the process of developing a funding application, the PIRO had engaged and gained the support of a number of service providers across the region to work together through mutually beneficial partnership arrangements in the implementation of PIR. Through this early, inclusive engagement, the PIRO was able to start positive conversations amongst service providers about how PIR would be of benefit to all relevant sectors, services and supports across the region.

During their three month establishment period the PIRO:

• employed the staff required to implement the initiative, including several Support Facilitators and a Project Officer
• negotiated an outposted arrangement for a number of the Support Facilitators to be co-located and based within the State funded community mental health teams, employment services, the Medicare Local, and Alcohol and Drug services (note: in any region, the viability of this arrangement would be based on specific negotiations with the relevant service providers)
• further developed the service mapping and gap analysis exercise submitted as part of their application for funding, to reflect the full breadth of the service delivery system in the region, and to confirm the strengths and gaps
• trained the Support Facilitators in the use of a number of resources, tools and templates to be used to implement PIR within the region, including:
  • operational guidelines
  • planning and communication tools
  • information sharing protocols
  • partnership building and governance protocols and tools
  • referral tools
  • a needs assessment framework
  • PIR Action Plan and
  • data collection and reporting protocols and tools.
• hosted a series of forums around the region (as a part of the PIR Communication Strategy) presenting information to consumers, carers, service provider staff, and others on:
  • what PIR is
  • who the PIRO is and its role
  • the importance of partnerships to the success of PIR and how the partnerships would be established, used and governed
  • the critical role of consumers and carers in the implementation of PIR within the region
  • the critical role of service providers within the partnerships and the benefits to be gained by active and sustained participation
  • the target population profile within the region and
  • the referral pathways into the initiative.
• established and convened a Medicare Local Region A PIR Intersectoral Group comprising PIR partners and others, including service providers across different sectors, consumers and carers across the region and
• negotiated other relevant governance arrangements, including a Regional Partnership Agreement, which sets out the respective responsibilities all partners across the region. Top of page

Medicare Local Region A PIR Intersectoral Group and Working Groups

The Medicare Local Region A Intersectoral Group (PIRIG) was established by the PIRO as a mechanism to bring all PIR partners together regularly to ensure collaborative, strategic oversight and ongoing review of the implementation of PIR in the region. The PIRIG provides a forum for service providers, consumers and carers to establish and monitor an agreed, strategic course of action to work together to improve the way services work together to meet the specific client needs across the region. The PIRIG also has a continuous quality improvement role to ensure lessons learned through implementation inform the ongoing evolution and roll out of PIR in the region (note: in some regions there may be existing structures that could be used/built on to perform this function).

The PIRO established a formal regional partnership agreement which all PIRIG members signed up to. The regional partnership agreement set out the roles and responsibilities of all PIRIG members and is regularly reviewed at PIRIG meetings to maintain its currency and usefulness.

Case-specific PIR Working Groups are established (under direction from the PIRIG or as identified by the Support Facilitator), as required, to enable relevant service providers, consumers and carers the opportunity to work together to plan how services will be delivered and sequenced to ensure the specific needs of PIR clients within the region are met. The type and nature of each Working Group is determined on a case by case basis.

The Support Facilitators have a key role in drawing the PIRIG and each Working Group's attention to areas of unmet need with regard to individual client PIR Action Plans. Support Facilitators will be the link between clients and their carers and families, and the service delivery system as represented on the Working Groups and PIRIG.

The PIRIG also provides an opportunity for the PIRO to keep service providers and other stakeholders across the region in the loop on the broader roll out of PIR. The PIRO has access to a national PIR organisation network, which provides a wealth of information on successful approaches being implemented in other regions, allowing information and resources to be shared through the PIRIG. The PIRO has invited PIR organisations from other regions to attend PIRIG meetings to present information about how PIR is rolling out elsewhere. The PIR National Evaluators have attended PIRIG meetings to provide information on lessons being learnt through the PIR roll out and to gather information on how PIR is being implemented in the region for the PIR national evaluation. Top of page

Medicare Local Region A PIRO Support Facilitation Team

The Medicare Local Region A PIRO Support Facilitation Team is responsible for the implementation of PIR across Medicare Local Region A. It comprises the head of the organisation (who may be a CEO or Executive Director for the whole organisation, and who has final legal liability for all funding for all programs and services the organisation delivers), the PIR Manager (who reports to the head of the organisation), the Support Facilitators and the PIR Project Officer.

The PIR Manager (and head of the organisation, as required) has a key role in establishing and sustaining the formalised arrangements that govern the PIR partnerships. The PIR Manager chairs the PIRIG and, in collaboration with the head of the organisation, as required, oversees the conduct of the regional partnership agreement and any MOUs established with service providers across the region.

The Support Facilitators are responsible for the day to day implementation of PIR across the region. They manage the PIR Working Groups, client referrals (including those that do not meet the inclusion criteria), assessment of clients' needs, and they drive the collaborative action planning and monitoring processes required to inform and guide the engagement of service providers. Support Facilitators attend the PIRIG meetings and generally Chair the Working Groups, and ensure ongoing communication across the region on PIR so all stakeholders are kept up to date on PIR progress, achievements and opportunities for engagement. Support Facilitators have a key role in data collection and monitoring and contributing to the evaluation of the initiative.

The PIR Project Officer supports the implementation of PIR by providing essential administrative support to the PIR Manager and Support Facilitators, and provides secretariat and administrative support to the PIRIG and Working Groups. The Project Officer also has responsibility for preparing the regular progress reports and other deliverables, contractually required by the Department, drawing on the broader PIRO and other structures as required.

The PIR Manager, Project Officer and Support Facilitators have regular meetings (including via teleconference) to discuss progress, address any issues and challenges, and plan for and schedule PIRIG and Working Group meetings.