Implementation and impact of an extended-hours service in mental health care: lessons learned

Abstract

Objective To describe the activity and impact of an extended-hours mental health service established to meet perceived need and improve service efficiency. Lessons developed in evaluation could usefully inform development of services in similar settings.

Setting A specialist mental health service providing assessment and treatment to 330 000 catchment residents of an Australian capital city.

Methods Pragmatic mixed-methods evaluation, combining review of 12 months service data and interviews with 65 stakeholders; with integration of descriptive statistics and thematic analysis of qualitative data.

Results Over 12 months, 2040 individuals were provided with a range of services during extended-hours, indicating that some sort of service was needed. However, evaluation demonstrated that flaws in assumptions underpinning the extended-hours service design, particularly regarding the population seeking after-hours care, necessitated adaptation of the proposed model. Ambiguity in purpose contributed to perceived lack of a cohesive identity, compounded by critical differences in the philosophies of care teams from which the extended-hours service clinicians were drawn. Nonetheless the service was considered effective by many stakeholders and co-location of different teams built collegiality within the service.

Conclusions A comprehensive needs analysis, enabling full description of target populations and their needs, should underpin establishment of any service. Such understanding is needed to ensure resources are appropriate. Importantly, because mental health clinicians are not interchangeable, matching philosophy of care and clinical skills to identified need is critical to quality and efficiency.

What is known about the topic? Public mental health services are obliged to deliver services which meet the needs of the service community in a timely manner. This requires enabling access to care outside routine business hours. However little is known about demand for after-hours service and literature provides little guidance to support efficient establishment of services.

What does this paper add? This mixed-methods investigation of a model of extended-hours service delivery provides insights to inform development of similar services. In addition to providing detailed information about provision of services in extended hours, we evidence the specialisation of mental health clinicians who work with particular populations typically accessing care after-hours. Risk assessment and crisis management are not ‘one size fits all’ and continuity and quality of care are enhanced when philosophy of care fits consumer presentations.

What are the implications for practitioners? Attention must be given to the often implicit assumptions underpinning establishment of any service. Critical to success are a thorough understanding of the problem to be addressed, clarity about and articulation of purpose and clinical pathways, and ensuring the skill mix is appropriate to need. The positive impact of co-location on collegiality will be optimised when resourcing is adequate. Further research is needed to understand the demand for after-hours service, particularly from the consumers’ perspective.