Development of a consumer advocacy program

Systematic synthesis of barriers and facilitators to service user-led care planning

BACKGROUND

Service user (patient) involvement in care planning is a principle enshrined by mental health policy yet often attracts criticism from patients and carers in practice.

AIMS

To examine how user-involved care planning is operationalised within mental health services and to establish where, how and why challenges to service user involvement occur.

METHOD

Systematic evidence synthesis.

RESULTS

Synthesis of data from 117 studies suggests that service user involvement fails because the patients' frame of reference diverges from that of providers. Service users and carers attributed highest value to the relational aspects of care planning. Health professionals inconsistently acknowledged the quality of the care planning process, tending instead to define service user involvement in terms of quantifiable service-led outcomes.

CONCLUSIONS

Service user-involved care planning is typically operationalised as a series of practice-based activities compliant with auditor standards. Meaningful involvement demands new patient-centred definitions of care planning quality. New organisational initiatives should validate time spent with service users and display more tangible and flexible commitments to meeting their needs.

Consumer-providers of care for adult clients of statutory mental health services

BACKGROUND

In mental health services, the past several decades has seen a slow but steady trend towards employment of past or present consumers of the service to work alongside mental health professionals in providing services. However the effects of this employment on clients (service recipients) and services has remained unclear.We conducted a systematic review of randomised trials assessing the effects of employing consumers of mental health services as providers of statutory mental health services to clients. In this review this role is called 'consumer-provider' and the term 'statutory mental health services' refers to public services, those required by statute or law, or public services involving statutory duties. The consumer-provider's role can encompass peer support, coaching, advocacy, case management or outreach, crisis worker or assertive community treatment worker, or providing social support programmes.

OBJECTIVES

To assess the effects of employing current or past adult consumers of mental health services as providers of statutory mental health services.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2012, Issue 3), MEDLINE (OvidSP) (1950 to March 2012), EMBASE (OvidSP) (1988 to March 2012), PsycINFO (OvidSP) (1806 to March 2012), CINAHL (EBSCOhost) (1981 to March 2009), Current Contents (OvidSP) (1993 to March 2012), and reference lists of relevant articles.

SELECTION CRITERIA

Randomised controlled trials of current or past consumers of mental health services employed as providers ('consumer-providers') in statutory mental health services, comparing either: 1) consumers versus professionals employed to do the same role within a mental health service, or 2) mental health services with and without consumer-providers as an adjunct to the service.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and extracted data. We contacted trialists for additional information. We conducted analyses using a random-effects model, pooling studies that measured the same outcome to provide a summary estimate of the effect across studies. We describe findings for each outcome in the text of the review with considerations of the potential impact of bias and the clinical importance of results, with input from a clinical expert.

MAIN RESULTS

We included 11 randomised controlled trials involving 2796 people. The quality of these studies was moderate to low, with most of the studies at unclear risk of bias in terms of random sequence generation and allocation concealment, and high risk of bias for blinded outcome assessment and selective outcome reporting.Five trials involving 581 people compared consumer-providers to professionals in similar roles within mental health services (case management roles (4 trials), facilitating group therapy (1 trial)). There were no significant differences in client quality of life (mean difference (MD) -0.30, 95% confidence interval (CI) -0.80 to 0.20); depression (data not pooled), general mental health symptoms (standardised mean difference (SMD) -0.24, 95% CI -0.52 to 0.05); client satisfaction with treatment (SMD -0.22, 95% CI -0.69 to 0.25), client or professional ratings of client-manager relationship; use of mental health services, hospital admissions and length of stay; or attrition (risk ratio 0.80, 95% CI 0.58 to 1.09) between mental health teams involving consumer-providers or professional staff in similar roles.There was a small reduction in crisis and emergency service use for clients receiving care involving consumer-providers (SMD -0.34 (95%CI -0.60 to -0.07). Past or present consumers who provided mental health services did so differently than professionals; they spent more time face-to-face with clients, and less time in the office, on the telephone, with clients' friends and family, or at provider agencies.Six trials involving 2215 people compared mental health services with or without the addition of consumer-providers. There were no significant differences in psychosocial outcomes (quality of life, empowerment, function, social relations), client satisfaction with service provision (SMD 0.76, 95% CI -0.59 to 2.10) and with staff (SMD 0.18, 95% CI -0.43 to 0.79), attendance rates (SMD 0.52 (95% CI -0.07 to 1.11), hospital admissions and length of stay, or attrition (risk ratio 1.29, 95% CI 0.72 to 2.31) between groups with consumer-providers as an adjunct to professional-led care and those receiving usual care from health professionals alone. One study found a small difference favouring the intervention group for both client and staff ratings of clients' needs having been met, although detection bias may have affected the latter. None of the six studies in this comparison reported client mental health outcomes.No studies in either comparison group reported data on adverse outcomes for clients, or the financial costs of service provision.

AUTHORS' CONCLUSIONS

Involving consumer-providers in mental health teams results in psychosocial, mental health symptom and service use outcomes for clients that were no better or worse than those achieved by professionals employed in similar roles, particularly for case management services.There is low quality evidence that involving consumer-providers in mental health teams results in a small reduction in clients' use of crisis or emergency services. The nature of the consumer-providers' involvement differs compared to professionals, as do the resources required to support their involvement. The overall quality of the evidence is moderate to low. There is no evidence of harm associated with involving consumer-providers in mental health teams.Future randomised controlled trials of consumer-providers in mental health services should minimise bias through the use of adequate randomisation and concealment of allocation, blinding of outcome assessment where possible, the comprehensive reporting of outcome data, and the avoidance of contamination between treatment groups. Researchers should adhere to SPIRIT and CONSORT reporting standards for clinical trials.Future trials should further evaluate standardised measures of clients' mental health, adverse outcomes for clients, the potential benefits and harms to the consumer-providers themselves (including need to return to treatment), and the financial costs of the intervention. They should utilise consistent, validated measurement tools and include a clear description of the consumer-provider role (eg specific tasks, responsibilities and expected deliverables of the role) and relevant training for the role so that it can be readily implemented. The weight of evidence being strongly based in the United States, future research should be located in diverse settings including in low- and middle-income countries.

The employment of consumers in mental health services: politically correct tokenism or genuinely useful?

OBJECTIVE

The aim of this paper is to examine the role of consumers as service providers and to describe the successful employment of peer support workers in a public mental health service.

CONCLUSIONS

The Peer Support Worker program in Adelaide, South Australia is consistent with evidence obtained from previous research in demonstrating the successful training and employment of consumers as peer workers in a public mental health service.

Consumers as tutors - legitimate teachers?

BACKGROUND

The aim of this study was to research the feasibility of training mental health consumers as tutors for 4th year medical students in psychiatry.

METHODS

A partnership between a consumer network and an academic unit in Psychological Medicine was formed to jointly develop a training package for consumer tutors and a curriculum in interviewing skills for medical students. Student attitudes to mental health consumers were measured pre and post the program. All tutorial evaluation data was analysed using univariate statistics. Both tutors and students evaluated the teaching program using a 4 point rating scale. The mean scores for teaching and content for both students and tutors were compared using an independent samples t-test.

RESULTS

Consumer tutors were successfully trained and accredited as tutors and able to sustain delivery of tutorials over a 4 year period. The study found that whilst the medical students started with positive attitudes towards consumers prior to the program, there was a general trend towards improved attitude across all measures. Other outcomes for tutors and students (both positive and negative) are described.

CONCLUSIONS

Consumer tutors along with professional tutors have a place in the education of medical students, are an untapped resource and deliver largely positive outcomes for students and themselves. Further possible developments are described.

Peer support/peer provided services underlying processes, benefits, and critical ingredients

The article defines peer support/peer provided services; discusses the underlying psychosocial processes of these services; and delineates the benefits to peer providers, individuals receiving services, and mental health service delivery system. Based on these theoretical processes and research, the critical ingredients of peer provided services, critical characteristics of peer providers, and mental health system principles for achieving maximum benefits are discussed, along with the level of empirical evidence for establishing these elements.

Involving users in the delivery and evaluation of mental health services: systematic review

OBJECTIVES

To identify evidence from comparative studies on the effects of involving users in the delivery and evaluation of mental health services.

DATA SOURCES

English language articles published between January 1966 and October 2001 found by searching electronic databases.

STUDY SELECTION

Systematic review of randomised controlled trials and other comparative studies of involving users in the delivery or evaluation of mental health services.

DATA EXTRACTION

Patterns of delivery of services by employees who use or who used to use the service and professional employees and the effects on trainees, research, or clients of mental health services.

RESULTS

Five randomised controlled trials and seven other comparative studies were identified. Half of the studies considered involving users in managing cases. Involving users as employees of mental health services led to clients having greater satisfaction with personal circumstances and less hospitalisation. Providers of services who had been trained by users had more positive attitudes toward users. Clients reported being less satisfied with services when interviewed by users.

CONCLUSIONS

Users can be involved as employees, trainers, or researchers without detrimental effect. Involving users with severe mental disorders in the delivery and evaluation of services is feasible.

Assessing outcome in community mental health patients: a comparative analysis of measures

BACKGROUND

We undertook a twelve-month intervention study for community mental health patients using a number of measures administered at baseline and at twelve months. Overall improvement in that sample allowed for comparative analyses of the key measures in terms of their ability to measure and to predict outcome.

AIMS

To assess and compare the usefulness of each of the measures in predicting outcome status.

METHODS

A patient-rated quality of life (QOL) questionnaire, the DSM-III-R Global Assessment of Functioning (GAF), the Life Skills Profile (LSP) and the Health of the Nation Outcome Scales (HoNOS) were compared and evaluated in a sample of seventy-nine patients.

RESULTS

The LSP appeared to measure disability only, while the HoNOS and the GAF assessed composite symptoms and general functioning. The HoNOS was identified as the most distinctive predictor of outcome.

CONCLUSIONS

The utility of the HoNOS as an overall service measure is supported, while properties and likely utility of other measures in outcome studies are detailed.

Development and evaluation of a training program in peer support for former consumers

While mental health policy in Australia promotes the involvement of mental health consumers in service planning, implementation and evaluation, little has been reported on the training required for the new roles that consumers are being expected to undertake. In this study, 10 former consumers of mental health services participated in a 16-week training program in peer support. The impact of the program on the psychological well-being of the participants was assessed using a battery of self-evaluation questionnaires and focus group interviews. Findings suggest that exposure to people with acute mental health problems (i.e. inpatients), did not, in this instance, adversely impact on the psychological well-being of the participants. Barriers to consumer participation in the mental health field are discussed and recommendations for the content and structure of future consumer peer support training initiatives are proposed.

A study of client-focused case management and consumer advocacy: the Community and Consumer Service Project

OBJECTIVE

The study investigated the provision of client-focused services to community-based clients with schizophrenia and bipolar disorder. It hypothesised that the delivery of more client-focused services would improve client outcome in terms of functioning, disability and satisfaction with services. Client-focused services were developed using an empowerment model of case management and by the addition of consumer advocates.

METHOD

Clients referred for case management were randomly allocated to one of three groups: standard case management (n = 35), client-focused case management (n = 39), or client-focused case management plus consumer advocacy (n = 45). Measures of functioning, disability, quality of life, burden of care and service satisfaction were measured at baseline and 12 months. Outcome data were collected concerning number and duration of hospital readmission, crisis intervention and compliance with treatment and services.

RESULTS

While there were no differences between the groups on quantitative measures of functioning, disability, quality of life, service satisfaction and burden of care, there were significant between-group differences on qualitative measures of satisfaction with services.

CONCLUSIONS

Several methodological difficulties hampered interpretation of the findings. Although clients did not differ on outcome measures of functioning and disability, the group receiving client-focused case management reported greater satisfaction with service delivery.