1. Changing practice to support self-management and recovery in mental illness: application of an implementation model
M Harris1, P Jones2, M Heartfield1, M Allstrom2, J Hancock2, S Lawn1, M Battersby1
1 Department of Psychiatry, Flinders University, South Australia.
2 UnitingCare Wesley Port Adelaide, South Australia
This presentation is a collaboration between Flinders University and UCWPA - an NGO provider for a range of services including community based psychosocial support for people with a mental illness.

3. The potential of implementation science
“Effective implementation requires a systematic, well-planned approach that considers all relevant factors” (Grol et al 2007 Milbank Quarterly 85:93-138)
“use of theories and frameworks ………. ensures that essential implementation strategies are included” (Tabak et al Am J Prev Med : )
The relatively new field of implementation science suggests that usual strategies are based on unexamined personal beliefs about human behaviour and organisational change and offers theories suggesting the factors which should be taken into account. However there is no generally accepted theory and the jury is still out on their usefulness.
This presentation describes a feasibility project where we identified and used one of these implementation frameworks during the introduction of a self-management support model in psychosocial care in Australia.

4. Study setting
Implementing the Flinders Program for all psychosocial care delivered by UnitingCare Wesley Port Adelaide
UnitingCare Wesley Port Adelaide
Provider of government funded psychosocial support in South Australia
Identified the Flinders Program to underpin recovery focus
Flinders Program
Collaborative, person-centred, care planning
Effective in mental health and physical chronic conditions and comorbidities
UnitingCare Wesley Port Adelaide provides government-funded psychosocial rehabilitation support to South Australians with severe mental illness. UCW wished to improve the recovery-orientation of its services and selected the Flinders Program as the new therapeutic process.
The Flinders Program (Flinders Chronic Condition Management Program) was developed by Professor Malcolm Battersby, Head of Psychiatry at Flinders University. It provides tools and structured motivational processes that the health worker uses with the person to collaboratively specify and achieve clinical and psychosocial goals. The program has shown effectiveness in mental health and physical health conditions and comorbidities of the two.
The team at UCW with academic partners from Flinders University aimed to use implementation research to inform the change-over to use of the Flinders Program by all 65 psychosocial care staff.

5. An implementation framework
Promoting Action on Research Implementation in Health Services – PARIHS (Rycroft-Malone et al 2002 Quality and Safety in Health Care 11: )
applicable to psychosocial support and rehabilitation
low burden measurement tool readily available
Organizational Readiness to Change Assessment – ORCA (Helfrich et al 2009 Implementation Science 4(1): 38)
Reviews have identified over 60 theoretical frameworks.
We wanted a framework that would be readily applicable in this setting. Because we wanted to know which factors from the framework were already in place and which needed targeting by additional change strategies, we also wanted a framework with closely linked low-burden measurement tools.
The framework known as PARIHS was the only one we could find that fully met these criteria. The corresponding measurement tool was the ORCA scale.

6. PARIHS and ORCA
PARIHS proposes that three key factors influence success of implementation:
evidence for the proposed change
supportiveness of the context
active facilitation provided
The ORCA measures the 3 key factors
77 items
some validation work published
Briefly, PARIHS proposes that stakeholder perceptions about three key factors predict implementation success. Later slides show the main concepts that contribute to each key factor.
The first is the evidence for the proposed practice change and as well as formal research evidence, professional experience or knowledge, and service user preferences are important
The second is quality of the organizational context and this includes organisational culture, general leadership practices and feedback, general readiness to change, and practical resources to support practice changes.
Active facilitation of the implementation includes leadership practices in relation to the project, project communication, and project planning and project resourcing.

7. ORCA results - evidence scale
July 2011
Mean (SD)
N=27
April 2012
N=17
Evidence Scale
Own view on strength of evidence
3.2 (0.88)
3.4 (0.77)
Expert colleagues’ views on strength of evidence
3.9 (0.60)
4.3 (0.75)
Research
3.5 (0.89)
3.8 (1.07)
Clinical experience
3.4 (0.87)
3.6 (0.81)
Patient preferences
3.4 (0.93)
3.6 (1.93)
Evidence scale overall
3.4 (0.91)
3.7 (1.37) p=0.03
I’ll talk about the Evidence subscale in most detail, because this is the factor that the model showed as rather lacking. Scores are out of 5.
Even though UCW leaders had selected the Flinders Program because of published evidence, and alignment with both a recovery orientation and person-centeredness, it appeared that this information had not been fully shared or taken on by the larger staff group.
This factor highlighted by use of the model was not being specifically addressed by the existing organisational change processes.
More information was therefore provided about published research and presentations were given at staff meetings. Also, training strategies were also moving staff into practice-use of the program for accreditation purposes, providing experience of the program – and positive clinical experiences feed into the ORCA evidence scale.
With these strategies, the evidence score did go up significantly (t-test 2 tailed, unequal variances), though there was potential to work further on this factor.
(The lower response rate for the second survey meant that changes in scores could reflect differences in the groups responding rather than changes in the organization over time.)

8. Implications
PARIHS and ORCA are feasible for use in real-practice psychosocial care
PARIHS appeared helpful
low perception on Evidence not otherwise visible
stepped up strategies matched by improved Evidence score
Unforseen benefits
“structure and data motivated players in the implementation”
Overall, PARIHS and ORCA were feasible to use and highlighted areas well covered and areas not being addressed by conventional change management strategies. They also kept the focus on implementation through some high-level staff changes in the organisation.
This feasibility study suggests that further use of implementation frameworks is practical and potentially fruitful in achieving best-practice change.