Recovery and support coordination in mental health in Waterloo-Wellington Dufferin: A new initiative and evaluation

"Recovery is the lived experience of persons as they discover, accept, and overcome the challenges of a disability, the effects of a psychiatric diagnosis or emotional or psychological trauma. It is discovering a new sense of self, of hope and purpose within and beyond the limits of these experiences. It is the discovery of one's own strengths and sense of power and control within oneself and the world. Finally, recovery occurs when a person's psychiatric diagnosis or emotional trauma is no longer the central focus in that person's life, but simply becomes a part of who that person is."

- From Empowerment Connection.

Welcome to our web page devoted to a set of new initiatives and partnerships in Waterloo-Wellington-Dufferin that are concerned with building, growing, and maintaining a mental health system that is guided by the principles of Recovery.  The Centre for Community Based Research is hosting this page on behalf of a local partnership of mental health organizations in the region.  In this webspace, we provide information and resources regarding recovery-focused policy and practice in the region as well as our progress and findings of an ongoing evaluation of recovery services.

April 2010 UPDATE!  This page includes new findings based on our evaluation research.  Click here to jump to the beginning of the findings section or browse the Table of Contents below to find specific information.  Please also have a look at project resources in the sidebar at right:  reports, fact sheets, presentations, articles!

Table of Contents:

1. Introduction
2. Recovery in Waterloo-Wellington-Dufferin
3. Recovery Principles and Values
4. Agency and Community Training in Recovery Focused Support Coordination
5. Evaluation of Recovery Focused Support Coordination
6. Building Recovery Focused Logic Models
7. What are Recovery Focused Outcomes?
8. Evaluation Findings and Resources
   1. Changes in the System and Practice
   2. Outcomes and Experiences of Service Users
   3. Access to Supports and Resources
   4. Community Integration
   5. Social Support & Relationships with Support Coordinators
   6. Pursuing Goals in Important Life Areas
   7. Empowerment, Control, and Interdependence
   8. Mental Health Recovery
   9. Some Additional Voices on Recovery
   10. Conclusion
       
9. Contact Information
10. Endnotes

Introduction

The mental health system in Ontario has been undergoing an important transformation for a number of years.  Provincial policy developments and grassroots advocacy by community groups has led to a critical understanding that it no longer makes sense for the mental health system to be a self-contained set of services removed from other aspects of human life.  This began back in the early 1990s with introduction of the "community resource base", a model that promoted a more holistic vision of mental health and wellness.

In this model, it was asserted that mental health and well-being was not only dependent upon support from mental health services, but from community resources, family, friends, and so on.Importantly, the outcomes of a good system were not limited to the usual indicators of mental health, such as relapse and medication compliance, but to domains of life important to most people in general, such as housing, income, work, and education.

The Community Resource Base was a precursor in the Canadian context to the wider conceptualization and use of the term "recovery", which has gained acceptance as a key principle in the mental health field the world over.  But what is recovery?  Many definitions have been advanced over the years but they all typically land on the idea that recovery is about a hope for the future, a belief in oneself to move beyond the illness label, the illness, and the system; and the ability to have control and voice one's own life and personal goals and journey.  This perspective is far removed from the narrow medicalized models of mental health that focus on diagnosis, treatment, and mental health maintenance.

Recovery in Waterloo-Wellington-Dufferin

In 2005, the Ministry of Health and Long-Term Care provided infrastructure dollars to the Waterloo-Wellington-Dufferin regions for the enhancement of intensive case management services.  Uniquely, this was "system focused" funding, rather than funding to be independently used by mental health service agencies.  A funding requirement was the creation of an ongoing multi-organizational partnership and consensus regarding policies and practices to improve and enhance case management services in the regions.  Eight mental health organizations comprise the Support Coordination Management Committee of Waterloo-Wellington-Dufferin:

• Canadian Mental Health Association, Grand River Branch

• Cambridge Memorial Hospital

• Dunara Wellington Dufferin Homes for Psychiatric Rehabilitation

• Grand River Hospital

• Homewood Health Centre, Community Division

• Self-Help Alliance

• St. Joseph's Health Care, London for Waterloo Regional ACTT

• Trellis Mental Health and Developmental Services

• Waterloo Regional Homes for Mental Health.

Consistent with recommendations from the "Kirby Report"², the Committee sought to enhance intensive case management services in ways that were consistent with the philosophy of mental health recovery.  This led to the development of a number of innovative mechanisms to stimulate mental health systems change in the regions.  First, the development of a Values and Principles consensus document and second, the creation of support coordinator and consumer training on "Recovery Planning".

Recovery Principles and Values

With the Self-Help Alliance as lead author, the Committee developed a set of principles and values of recovery to which all relevant policies and services of the partnership would be accountable.³  A central recovery value is expressed as follows.

…a belief that recovery is possible and there is a belief in a person's ability to recover and that there is hope about the future.  Recovery is about meeting and accepting a person for where they are at and at the pace in which they will move forward.  An individual's greatest strength is who they are.

Following this value, the Values and Principles document promotes a recovery oriented mental health system that will :

1. Value Empowerment - The system will provide opportunities for individuals to exercise control and power with respect to their lives.

2. Value and Instill Hope - Recovery cannot occur without hope.  The system will encourage hope and in doing so will focus on skills and abilities.

3. Value Self Determination - The system will recognize and accept that consumers will make their own decisions about their life and they will be in control of those decisions.

4. Work toward the Elimination of Prejudice and Discrimination - The system will work toward the elimination of prejudice and discrimination toward people with mental health issues.

5. Value Meaningful Choice - The system will recognize and accept that individuals will make their own decisions about their life and they will be in control of those decisions.

It is of great significance that the Self Help Alliance, an independent self-help umbrella organization, authored the Values and Principles document, in collaboration with the Committee.  This recognizes a consumer-run organization as an equal partner on the committee and ensured meaningful community representation in the development of recovery focused mental health services.

**Download "Values and Principles" document.

Agency and Community Training in Recovery Focused Support Coordination

One of the biggest challenges to transforming mental health systems is moving from recovery as a value position to actual practical development and implementation of services and supports that reflect this position.  The central, system-wide intervention in moving toward recovery focused mental health services was the development and delivery of recovery focused training.  Case managers and people who use mental health services received training on recovery values and principles, and the use of Recovery Action Plans with service users.  Recovery Action Plans are the main intervention in the community via the work case managers carry out in partnership with consumers.

Recovery planning involves ongoing dialogue between case managers and service users and the development of personal plans for recovery.  While all contemporary approaches to case management tend to include a personal planning component, the incorporation of recovery focused planning is relatively new.  In our local system, case managers and service users have been trained on how to develop a step-by-step plan wherein service users begin by selecting the areas of life they would like to focus on. Usually one to three of ten areas are selected.

Table 1 - Ten Goal Areas of Recovery Planning

The planning process then involves dialogue with service users regarding their own self-awareness of needs and how dependent they are on others to fulfill these needs.  This is followed by determining levels of motivation, urgency, support available, and ease of progressing towards a range of goals.  Service users then select one or two specificgoals to work toward.  At this point, the plan begins to take form, as service users begin to identify the skills and knowledge they need to pursue their goals, concrete strategies to do so, and other community resources that would help support the process.

Evaluation of Recovery Focused Support Coordination

CCBR is working with the partnership to conduct a long-term evaluation of the process and impact of systems-level changes to policy and practice that follow from a new emphasis on recovery.  The current focus is on the impact of recovery focused support coordination.  The overarching purpose of the evaluation is:

To understand how a recovery focus in the Waterloo-Wellington-Dufferin mental health system leads to positive changes for individuals using support coordination services.

There are also a number of subquestions are trying to answer, including:

• How and to what extent is a recovery focused approach to support coordination helping service users to improve their mental health & stability and reach their personal goals?

• Are people getting what they want (in terms of services and support)? Why not? If not, what are they getting?

• To what extent are people beginning to dream about recovery and are hopeful that they will reach their goals?

• To what extent are people active in their recovery plan - taking risks, practicing options, and achieving learning and confidence?

• How are recovery-focused values permeating the day-to-day work of support coordinations and others in the mental health system?

Building Recovery Focused Logic Models

A logic model is a visual diagram that displays the ways in which an initiative's or program's activities are linked to short- and long-term outcomes.  Outcomes refer the positive benefits or changes experienced by program participants.  Logic models serve many important functions.  First, they help decsribe complicated programs and allow users to analyze the assumptions that are being made about how the program works (e.g., what activities lead to what outcomes and why?  Are these connections reasonable?).  Logic models also provides a common language that all program stakeholders can understand, therefore facilitating dialogue about the program.  Logic models are a useful aid in setting evaluation priorities and questions and generating strategies for measuring program implementation and outcomes.  Logic models also can serve as useful mechanism for community participation and continual program improvement and planning.

While we already had a lot of good ideas as to what activities and outcomes are recovery focused, it was important to explore these ideas from the perspective of stakeholders in the local mental health system.  We held three logic model workshop sessions.  Two workshops each were held with services users, one each in Guelph and Kitchener, and an additional workshop was held for support coordinators and program managers from agencies in the partnership.  The logic models were built in "real time", using an overhead projector and Microsoft Powerpoint software.  Thus, the models emerged during the workshop allowing participants to continue to provide feedback and modifications.  An important side benefit of this process was its active and participatory nature and the sense of co-ownership over the emerging model.

We created two models, in Figures 1 and 2 below.  The first model details the desired impact of support coordination services as experienced by service users (The Service User model).  The second details the impact of systems-level activities (such as support coordinator training) on the service and system (The Service and System Logic Model).  Click on the models for larger images and/or check out the presentation at the top right which provides more information about specific pieces of the model.

Figure 1 - Service User Logic Model (click to enlarge)

Figure 2 - Service & System Logic Model (click to enlarge)

What are Recovery Focused Outcomes?

The logic model sessions led to an interesting picture of what we might called Recovery Focused Outcomes.  These are benefits to service users (and thus are shown in the Service User model) that are supportive and representative the process and experience of recovery.  As Jacobson (2000) points out, recovery is not a "cure-like" endpoint, but a state of being, and "a path rather than a destination".⁴  We hope our model, to some extent, has captured this.  Recovery focused outcomes add to and improve upon previous approaches to mental health outcomes.

In the past, mental health outcomes have often been medicalized and diagnosis focused, referring to things like hospitalization rates, symptom reduction, and medication compliance.  As mental health services became more community oriented, outcomes tended to reflect the goals of psychosocial rehabilitation, such as improved life skills and problem solving, greater social support and community participation, improved quality of life, and so on.  Alongside the frameworks of mental health services, consumer/survivor movements began describing empowerment focused outcomes.  Empowerment outcomes are concerned with things like self-determination, sense of control, self-advocacy, and civic participation.

Recovery focused outcomes refer to the personal journey of recovery, but also include empowerment focused outcomes as equally important.  For example, recovery outcomes include "hope", "belief in recovery", "goal planning and setting", and "risk-taking".  Below are some examples from each the major approaches:

Medical, professionalized outcomes: Symptomatology, hospitalization, recidivism, service usage, medication compliance, other health behaviors.

Psychosocial outcomes: Quality of life, physical activity, general health, life skills, problem-solving, social support, community participation.

Empowerment outcomes: Self-determination, feelings of empowerment, sense of control, personal & social advocacy, citizen participation.

Recovery outcomes: Empowerment focused outcomes, hope, belief in your personal dreams, belief that recovery is possible, goal-setting, taking risks, improved confidence, sharing the healing process, moving beyond the label, sense of renewal & spirit, dignity & self-respect, self-fulfillment.

Evaluation Findings

Interviewer: When you started your recovery plan, what role did you have in developing it?

 

Service User: I had a big role in it, actually. They allowed me to come up with the idea that education was the main thing I would concentrate on. I just needed the help, kind of like a hand up to do that.

---

Interviewer: What are some of the useful things you've learned through your recovery process?

 

Service User: I've learned I should always have a goal.

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This evaluation research project collected information on the the system-wide development of the recovery planning process and the impact it has had on important recovery related outcomes for people using support coordination services.  We approached this project by collecting this information during the beginning of the change to recovery focused practice and the use the recovery planning tool ("baseline") and then again one year later ("follow up"). Below is a selection of our findings.

Please also see the side bar at right to download our evaluation reports, fact sheets, and other resources!

Changes in the System and Practice

 I think [recovery] is more at the forefront… it's just the whole language around it that's shifted people's thinking - support coordinators and people supported. And you can see it in the community. - Service Provider

 

An expectation of this system-wide initiative was that a common and consistent approach to recovery planning would evolve and would promote positive attitudes towards recovery among staff, leading to systemic changes in practice.  Most support coordinators and supervisors were of the view that these expected system-wide changes are taking place.

There was wide support for the values and principles of recovery among support coordinators.  The majority of support coordinators who participated in this evaluation also felt supported by their organizations in doing recovery planning in both phases of the evaluation.  They told us that their agencies were incorporating the values and principles of recovery into all aspects of their work.

Additionally, many support coordinators noted that the introduction of system-wide planning tools and training have provided a "common language" and increased consistency across the mental health system.

 

Consistency across a service system, even in a city the size of Guelph, feels good - you've got the three main players in terms of mental health, we're all speaking the same language which hasn't happened, I'm not sure its ever happened.  And we're using the same language at planning tables and also on the front lines.  It feels really good. - Support Coordinator

 

Recovery planning has increased in the system.  At follow up, support coordinators were engaged in recovery planning with more service users than they were at baseline.  Most support coordinators who participated in the evaluation also noted that recovery planning has improved their communication and relationships with service users.

Furthermore, many support coordinators expressed that recovery focused support coordination is yielding many useful outcomes, both for the system and for service users.  For example, a greater proportion of support coordinators agreed to the following statements at follow up compared to baseline: 1) "the recovery planning process improves consumers' knowledge and awareness of the recovery process", and 2) "the recovery planning process helps improve the knowledge and skills consumers need to pursue their personal goals".

There were, however, a few challenges to recovery planning during the process of change and collaboration.  An initial challenge was the length and complexity of the recovery planning tool.  Early on, support coordinators were starting to equate "completing the tool" with "doing recovery".  This meant that some service users who found the tool too complex or long were considered "not ready for recovery planning".  Over time, support coordinators wrestled with the problem and organizations responded in two major ways:

 

1. Ensuring that recovery is not viewed as completing a tool, but an open, supportive conversation about moving towards one's goals.  A tool may help this conversation, but recovery planning IS having the conversation, no matter how modest.  The principle is that everyone can engage recovery planning by beginning this conversation.

2. Each organization modified the tool to meet its needs based on feedback from support coordinators and users.  The system agreed the following core components of recovery planning should be represented in any tool and in ongoing recovery focused conversations:

a) The ten components (goal areas) of recovery

b) Specific goals of the service user within those areas

c) The skills and knowledge needed to achieve these goals, and important community resources to support them.

d) The specific plans or action steps that will be taken to meet the goals.

Outcomes and Experiences of Service Users

Interviewer:  How much influence do you feel you have in the planning?

 

Service User: Total.  If he suggests something or we discuss something that I'm against, it's dropped. [My support coordinator] is really good in that way where he doesn't push things that don't need to be pushed.  He does sometimes with things that need to be pushed, but if I say no and give him a reason he says 'okay, I understand, great.'

Our model of recovery planning suggests there are groups of core outcomes that we can expect to follow from recovery-focused support coordination.  Using a range measures and tools, the evaluation compared outcomes at baseline and follow up.  Below are some selected findings.

Access to Supports and Resources

A core activity of support coordination is to link service users to a range of supports, services, groups, and communities and to help foster the relationships that result.  This is highly relevant to many of the goal areas of recovery planning, such as access to resources, community involvement, and peer support and relationships.

The findings of this evaluation indicated that this was happening in the system.  Service users who were engaged in recovery planning were more likely to access other community mental health resources than those who were not engaged in recovery planning.

Community Integration

Recovery planning was also associated with higher levels of community integration.  On average, service users who had recovery plans were more involved in their communities than service users without recovery plans.  Furthermore, among service users who have recovery plans, those who have focused on the "community involvement" goal scored higher on a measure of community integration than those who have not.

Social Support & Relationships with Support Coordinators

There were no significant differences in feelings of social support between service users who were engaged in recovery planning versus service users who were not.  Both groups scored fairly high on a measure of social support.Qualitative data reflected this, showing many examples of how support coordination was related to social support.

 

[My support coordinator] helps me to be more social, and that definitely makes a difference… So as I feel better and I'm up more often, the chances of me having social relationships- and I'm not just talking about female I'm talking about having friends and all those type of relationships - mind you the female one is the one I miss the most - it's all process, getting more friends, meeting more people, the chances are better. - Service User

 

Service users with or without recovery plans appeared to have good relationships with their support coordinators (based on a "Staff Relationships" measure).  Service users in the two regions enjoyed good relationships with their support coordinators irrespective of whether or not they were pursuing recovery planning.

Pursuing Goals in Important Life Areas

The findings of this evaluation indicated that service users engaged in recovery planning were more likely to be pursuing personal goals in important life areas as compared to service users who were not engaged in recovery planning.  This finding was important because early in the process of introducing the new recovery tool, a number of support coordinators suggested that they were "already doing recovery".  This finding suggests the new emphasis on recovery planning has led more active planning than before.

Empowerment, Control, and Interdependence

A measure of empowerment was higher for those engaged in recovery planning.  This is an important indicator of control and self-determination.  Furthermore, individuals engaged in recovery planning had higher scores on a measure of interdependence, which is the degree to which individuals are mutually connected and involved in relationships with others.

Mental Health Recovery

A recovery focused approach to support coordination has had a significant impact on overall recovery as measured by the Mental Health Recovery Measure (MHRM).  The MHRM is designed to assess the core features of recovery, including knowledge of the concept of recovery, feelings of hope, and dreaming about recovery, power and control, risk-taking, action, and confidence.  On average, the MHRM scores of service users engaged in recovery planning were significantly higher than the scores of service users who were not engaged in recovery planning.  Other important measures, such as community integration, empowerment and interdependence were strongly correlated with mental health recovery.

Interestingly, independence was not correlated to the MHRM. Independence reflects basic psychosocial outcomes, such as maintaining housing, finances, food security, and basic relationships necessary for community living.  Why would independence not relate to our measure of recovery?  An important hypothesis is that mere independent living does not equate with a rich, connected, and fulfilling life.  This suggests that basic psychosocial outcomes may not be the best indicators of "success" when examining a recovery focused system. Interdependence, empowerment, and recovery are outcomes that better represent the goals of a recovery approach.

Some Additional Community Voices on Recovery

Interviewer:  How is your life compared to prior to starting recovery planning?

 

Service User: Well, because I didn't have the plan there was no focus to what I was doing. I guess I was just living day to day. Now I feel I have a purpose with my life.

---

 

 

See recovery's a very big thing. For many years I wanted to be what I used to be and I've come to realize, that's not going to happen. So the recovery is setting goals that are attainable, that I know I can reach.  - Service User

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Service User: What are some of the useful things you have learned through your recovery process?

 

 

 

Service User: Going out there and saying to myself that there's no way that you can say there's no help.There is help for us to recover.

---

 

Service User: How would you compare your life now to your life prior to starting the recovery process?

 

 

 

Service User: You just have to take risks, its different being all by yourself, you have to move forward no matter what.

Conclusion

In conclusion, the findings of this evaluation provided evidence that the recovery focused model of support coordination has had a positive impact on the mental health service system in the Waterloo and Wellington-Dufferin regions.  The system collaboration has been very successful, with multiple organizations endorsing a set of shared values and common practices.

Consistent with our expectations and the intent of the intervention, individuals who are engaged in recovery planning are experiencing better overall outcomes than individuals who are not engaged in recovery planning:  Recovery focused mental health service users were more likely to be focused on improving specific aspects of their lives, they were more likely to use other mental health supports in their communities, and were more integrated into their communities.  Moreover, recovery focused service users had more power and control over their lives at follow up compared to service users who were not engaged in recovery planning.

Overall, this evaluation has demonstrated an innovative system-level approach to improving support coordination services while also suggesting how a recovery focus can inform mental health policy and practice in general.

Project Resources

In this project, we have produced many presentations, reports, summaries, fact sheets and articles.  We encourage you to download these resources and share them with your colleagues.  They are listed in the grey sidebar on the right-hand side of the page.  For more information, see the contact information below.

Contact information

Please contact Helen Fishburn at Trellis Mental Health and Developmental Services for more information about mental health and recovery in the Regions of Waterloo-Wellington-Dufferin. hfishburn@trellis.on.ca.

Please contact Allan Strong of the Self-Help Alliance about community education in recovery and how you can become more involved.  stronga@self-help.ca

Please contact Jonathan Lomotey of the Centre for Community Based Research regarding the findings of this evaluation and ongoing evaluation activities. jonathan@communitybasedresearch.ca

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Endnotes:

1. Trainor, J., Pomeroy, E. and Pape, B. (1993). A new framework for support for people with serious mental healthproblems. Canadian Mental Health Association.

2. Standing Senate Committee of Social Affairs, Science, and Technology (2006). Out of the Shadows: Transforming Mental Health, Mental Illness, and Addiction Services in Canada. Government of Canada.

3. Self-Help Alliance (2006).Recovery values and principlesin the mental health service system.Policy document of the Support Coordination Management Committee of Waterloo-Wellington-Dufferin.Guelph, ON: Author.

4. Jacobson, N. & Curtis, L. (2000). Recovery as policy in mental health services:Stategies emerging from the States.Psychiatric Rehabilitation Journal, 23 (4), 333-341.

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