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List of figuresFigure 1 PCLI Phases June 2014– December 202012Figure 2 Strategic drivers for the PCLI18Figure 3 PCLI Framework27Figure 4 Governance componentsof the PCLI28Figure 5 Communication Methods30Figure 6 PCLI Training Modules33Figure 7 LHD Assessment Process36Figure 8 The Person’s Assessment Process37Figure 9 Example of PCLI Partnership Drivers40Figure 10 Summary of the PCLI Program Logic41List of tablesTable 1 Total beds on major mental healthsites in NSW – funded beds asof June 201421Table 2 Annual mental health admissionsto the six main hospitals involvedin PCLI, 2012-201622Table 3 Primary implementation sites22Table 4 Dialogue Days upuntil 31 December 201631Table 5 PCLI Training up until December 201634Table 6 Assessment Tools for the PCLI35Table 7 Size of the PCLI Cohort,June 2015 to December 201638AppendicesAppendix 1 PCLI Program LogicAppendix 2 PCLI Evaluation FrameworkNSW Health5051Pathways to Community Living Initiative: Evaluation Report 13

Executive summaryThe Pathways to Community Living Initiative(PCLI) was established to support the transitionof long-stay mental health patients into appropriatecommunity-based services. This is occurringas part of a decade-long whole-of-governmentenhancement of mental health care under theNSW Mental Health Reform 2014-2024, withsignificant investment by the NSW Government.The PCLI is led, funded and coordinated by theNSW Ministry of Health in collaboration with LocalHealth Districts.The PCLI represents a system-widetransformational change for consumersand their families and the mental healthworkers who care for them. It is a significantinvestment in redesign of the way thatmental health services are being delivered,particularly for consumers with long-termneeds.This is a challenging initiative, requiring sustaineddedication and commitment as it involves: changing the knowledge, skills and attitudesof staff within mental health services; establishing new and/or enhanced partnershipswith other organisations and sectors; introducing new models of care with adaptationsto existing work practices; and sustaining a recovery-oriented and personcentred approach to working with consumersand their families/carers.Purpose of this reportThis document is the first evaluation report for thePCLI and is intended for a broad audience. It coversthe period from mid-2014 to December 2016. It isthe foundational report and as the first in a series,provides a reference point for all subsequentevaluation reports. The report captures thepreliminary planning, context, history, andearly stages of program development andimplementation. It articulates the depth andcomplexity of this major program of practiceredesign, changing practices from the usual waysof doing things that have been in place for manyyears. Through a focus on formative evaluationissues it highlights program achievements fromconceptualisation and development, planningand the initial implementation phase.4The report has been produced by the evaluationteam from the Centre for Health ServiceDevelopment at the University of Wollongong,commissioned to undertake a formative andsummative evaluation of the program. It is theproduct of a collaborative approach with theMinistry PCLI team.Aims and scope of the PCLIThe PCLI has the twin aims of: transitioning 380 long-stay patients who havebeen mental health inpatients in either acuteor non-acute inpatient units for over 365 daysto appropriate community based servicemodels; and providing improved and sustainable carepathways that embed a recovery approachfor people with enduring mental illness.The 380 people within the original cohort reflecttwo distinct groups: Adults with issues of ageing, approximately 100(Stage One) Adults without issues of ageing, approximately280 (Stage Two)The PCLI is being implemented across NSWfrom mid-2014 to the end of 2020; however,a transformational change of this scale willrequire the best part of a decade to embedthe patient pathways and service models.There are six primary implementation sites:Macquarie Hospital, Cumberland Hospital, MorissetHospital, Bloomfield Hospital, Concord MentalHealth Centre and Liverpool Hospital. Liverpoolwas the last to join the PCLI.State of playThe analysis draws on data from the HealthInformation Exchange collated by InforMH.The PCLI became operational in Local HealthDistricts in mid-2015 with early efforts investedin patient assessment and pre-transition planning.By October 2016 more than 200 long-stayconsumers had been assessed and transitionswere gradually building.Pathways to Community Living Initiative: Evaluation Report 1NSW Health

According to data from InforMH the mental healthinformation unit, in the Ministry of Health (reportedby hospital) for the period mid-2015 to December2016, the size of the PCLI cohort decreased by 3%.There was an increase in the cohort at LiverpoolHospital but this was from a low base and mayreflect local factors, a similar explanation isproffered for the long-stay cohort scatteredacross multiple ‘other’ facilities which also slightlyincreased. Three of the other main sites achieveda reduction in the PCLI cohort over this time periodand there has been no change overall in two sites.More comprehensive reporting on assessments andtransitions will be included in Evaluation Report 2(up to June 2018) and updated in Evaluation Report3 (up to December 2018).Policy environmentMethods Identifying differences in local context (the PCLIimplementation sites), contributes tounderstanding how and why the program works,or doesn’t.The evaluation team’s engagement commenced inJanuary 2017. As the period of this report precedesthis, the data sources for Evaluation Report 1 aredocumentary. Websites have been accessed toverify events and the evaluation team has had theopportunity to engage stakeholders in informalconversations about the early days of programdevelopment. The recent release by the MentalHealth Commission of NSW (2018) of, Paving theway home, Lessons from My Choice: Pathways toCommunity Living Initiative, Spotlight on Reformhas provided a useful touchstone to compare thefindings of this report.Transformational changeThe PCLI meets the working definition of largesystem transformation as it represents acoordinated, system-wide change affecting multipleorganisations and care providers. The purpose ofthe initiative is improvement in the health outcomesof the current cohort of long-stay mental healthpatients through introducing new models of careand permanently changing the pathways of care forpeople with persistent and complex mental illness.The Mental Health Commissioner hasreferred to the PCLI as ‘transformational’because it will change the lives of peoplewith mental illness, and will also betransformational for the staff and workersin mental health (NSW 2017a, p.9).NSW HealthPathways to Community Living Initiative: Evaluation Report 1The receptive context for change arose froma confluence of policy developments whichcontributed to the NSW Government’s investmentin this initiative. The PCLI is a key component of theStrategic Plan for Mental Health in NSW 2014 –2024 and aligns with the major recommendationsof the NSW Mental Health Commission documentLiving Well, A Strategic Plan for Mental Health inNSW 2014 – 2024. The development, implementation and evaluationof the PCLI has to be understood in terms of theprevailing contextual conditions. Changes in NSW mental health policy providedthe impetus for change. NSW Health is a decentralised organisationand can be characterised as a complexadaptive system. The behaviours of complex adaptive systemscan usually be more easily influenced thancontrolled, consequently introducing change in acomplex adaptive system is unlikely to work witha command and control approach to leadership.Using the lens of complexity may help ourunderstanding of some of the challengesfacing implementation of the PCLI.Program developmentThe genesis of the PCLI, like many transformationalchanges in mental health care, built slowly overseveral years from discussions amongst passionatemental health workers, clinicians, consumers andcarers who fundamentally understood that ‘ahospital is not a home’ (a phrase attributed to thePCLI consumer lead). This willingness to challengewhat was an accepted paradigm or model of carefor long-stay patients with enduring mental illnessand explore more contemporary pathways of careled to the PCLI.5

The impetus for change came from a confluenceof factors including: analysing the available data on long-stay patientsin NSW mental health facilities; assessing the needs of long-stay patients withcomplex mental illness; recognising a receptive policy context supportiveof complex care individuals, where possiblehaving the right to live in the community; synthesising the evidence to inform new modelsof good quality community care; modelling different service options and preparingcostings; leveraging off the experience of others throughcross sectoral partnerships and advocating forbipartisan support; communicating with State agencies, regulatorybodies and other potential stakeholders; embracing the advent of the NDIS shifting thefocus for service provision to a wider and moreintegrated community responsibility; harnessing the vision of committed individualsin LHDs who needed support; and adopting a planned approach to initiatingthe change.Achievements in programdevelopmentThe process of program developmenthas been characterised by vision, energyand commitment.This has spanned preliminary design anddevelopment work that began in May/June 2014which includes: recognising a program’s ‘time has come’ andinitiating action for change; establishing an implementation team for thePCLI both within the Ministry and throughfunding positions in the Local Health Districts; reviewing the evidence about models of care andpatient outcomes; ways to measure readiness totransition as well as barriers to transition for thispatient cohort;6 communicating extensively with Chief Executivesand Mental Health Directors of Local HealthDistricts; drafting media releases for the Minister;producing fact sheets targeted at staff workingin mental health care in NSW and for consumerstheir families and carers; and presentingextensively to various stakeholder audiences,forums and conferences; building on the lessons from previousexperiences, such as the development ofSpecialist Mental Health Services for OlderPeople in NSW over the last 10-15 years andthe experience of successful transitioningof long-stay mental health patients fromKenmore Hospital; developing initial costings to Treasury andinternal business cases to inform the NSWwhole-of-government reform processStrengthening Mental Health Care in NSW,announced in December 2014 and contributing tothe Mental Health Reform Business Case that wassubmitted to the Economic Review Committee ofCabinet in August 2015; securing the inputs for the program (i.e. theresources that are invested to make the policyor program happen). Examples of such inputsinclude new policies, additional funding,additional staff and the establishment ofpartnership arrangements; identifying the PCLI patient cohort and throughsegmentation facilitating a staged approachto service development (Stage One and StageTwo); and establishing the six primary implementation sites.Program implementationThe planning and initial implementation periodextends up until December 2016. A detailed workplan is produced annually and used to monitorprogram milestones, as at December 2016 programimplementation is on track.The Ministry PCLI team is driving thiscomplex change initiative using themechanism of the PCLI quadrant modelwhich depicts the four implementationcomponents or ‘quadrants’ of action.Pathways to Community Living Initiative: Evaluation Report 1NSW Health

The four quadrants comprise: ‘project/program processes’ includinggovernance and leadership, communicationmechanisms, change and innovationmanagement and workforce development; ‘getting to know you’ referring to individualplanning and assessment; pre and post transitionand transitions to community living; ‘service development’ comprising modelling,enhancements and tenders and partnerships, and ‘information and evaluation’ consisting of thePCLI program logic, data collecting and reportingand evaluation.Achievements in programimplementationThe major achievements in this period include: implementing effective underpinning programprocesses such as governance and leadership ofthe PCLI, communication, change and innovationmanagement and workforce development; working collaboratively to build a distributedmodel of leadership with clear roles for theMinistry PCLI team and Local HealthDistrict partners; initiating pre-transition assessments across thesix primary implementation sites and transitioning3% of the long-stay patient cohort to appropriatecommunity living; completing the procurement plan and releasingtender documents for Mental Health - ResidentialAged Care Partnership Services (an expansionunder the PCLI) and Specialist Residential AgedCare Facilities. This process was informed by acosting study of mental health residential agedcare services; planning for the second stage of servicedevelopment for people who are younger,aged 18 years upwards without issues of ageing; building the initial data repository for PCLIspecific data items and subsequently transferringthis to an Access database to improve usability; establishing the Data and InformationManagement Group to ensure that data iscollected and available for health planningpurposes, reporting and evaluation of thePCLI program; developing the Evaluation Framework Modeland engaging an external and independentevaluation team.Summary of challengesmoving forward andrecommendationsIssues emerging through the evaluation process aresummarised below using constructs to symbolisethe five ‘simple rules’ that can enhance success intransformational change. Recommendations foraddressing each challenge are included.LeadershipSimple Rule 1: Engage individuals at all levels inleading the changeThe PCLI currently has a model of distributedleadership in place. The pressure to generatemomentum required a more directive approachin the early phase of the program. Over time thependulum has swung back to the distributedleadership model and this has been demonstrated bycommunicating widely the aims, vision and strategiesat the core of the PCLI and the focus on developingshared leadership of program processes.What is clear is that in a distributed leadershipmodel the change still needs to be managedactively and the Ministry continues to do thisthrough supporting implementation sites andworking hard to influence the wider NSW mentalhealth service delivery system. facilitating partnerships with diverse stakeholdersto speed implementation, for examplepartnerships with NGOs and aged care providers;Recommendations finalising the PCLI program logic which sets outthe strategic objectives, performance activities,outputs and intended outcomes of the PCLI;1. Continue to foster the distributedleadership model throughoutimplementation of the PCLI.NSW HealthPathways to Community Living Initiative: Evaluation Report 17

Collaborative monitoringand measurementSimple Rule 2: Establish feedback loopsRoutine reporting and celebrating programsuccesses provides fuel to sustain implementation.The PCLI is a complex intervention and ongoingmonitoring and evaluation is essential to ensure thatthe program is feasible, appropriate and acceptableand that program activities are being implementedas intended.Those engaged in the PCLI and externalstakeholders need to receive information aboutintermediate outcomes, for example completedassessments, training of LHD personnel or evidenceof changes in work practices to facilitate new andimproved care pathways. The Ministry PCLI teamhas used the six-month reporting template tocapture achievements and the Dialogue Daysto celebrate successes, both are usefulmeasures. The PCLI Collaborative Group weeklyteleconference is another important mechanism.The challenge ahead is to sustain implementationand keep LHD personnel and other stakeholdersinvolved as the PCLI ‘is a marathon and not a sprint’and there is a real risk of ‘change fatigue’. There isan ongoing need for training and vigilance incommunicating the aims, purpose and processesof the PCLI. Providing feedback to mental healthpersonnel about the PCLI evaluation is alsoimperative as their participation in interviews,surveys and observational site visits is essentialto the evaluation.Recommendations2. Review the PCLI Communication Plan toextend the reach to stakeholders withinand external to NSW Health and ensurethat messages reflect the stage ofprogram development.3. Assist those engaged in the PCLI to haverealistic expectations about the trajectoryof the evaluation and encourage their fullparticipation.8History and contextSimple Rule 3: Attend to historySuccess depends on local history and a carefulanalysis of what has gone before. At the timeof development the Ministry PCLI teamdemonstrated a sophisticated understandingof the prevailing mental health policy context andthe role of the PCLI in meeting high level mentalhealth reform objectives.Each implementation site has its own localhistory, culture and unique mix of challenges.The patient cohorts also differ significantlybetween the sites and this means that variousresources will be needed to manage patientseffectively in the community.Recommendations4. Influence entrenched cultures throughconsistent messaging, evidence ofsuccess and program adaptations inresponse to unforeseen challengesand stakeholder feedback.Clinical engagement and co-designSimple Rule 4: Engage physiciansDoctors are of crucial importance to health systemtransformation because of their positional powerand influence as opinion leaders. Appointing theNSW Chief Psychiatrist as the program sponsorreflected awareness of the need for medicalleadership as did the engagement of a programclinical lead. However in an initiative of this scalewide engagement with the full spectrum of mentalhealth workers is essential.There is a need to balance achievement of programobjectives and targets with maintaining servicedelivery. Similarly a balance has to be struckbetween standardising processes across theState and allowing flexibility to accommodatelocal need

to achieve a life outside hospital for the first time in years. . (Orange Health Service) 23 2.7.2 Concord Hospital 23 2.7.3 Cumberland Hospital 24 . 3.2.1 Individual planning and assessment 35 3.2.2 Pre and post transition 37 3.2.3 Transitions to community living 38