BackgroundNurse Practitioners work independently and collaboratively within multidisciplinary teams to fill unmet service delivery needs. Despite strong evidence of the benefits of the nurse practitioner service model, organisational support for nurse practitioners varies in terms of resources and support from leadership and other healthcare professionals.AimsThe study aimed to explore healthcare practitioners' experiences of implementation of a NP service in a rural setting.MethodsSemi-structured interviews were conducted with ten healthcare practitioners to investigate their perspectives of a recently implemented NP service. Data were analysed inductively using thematic analysis.FindingsThemes emerged related to facilitating collaborative practice, person-centred continuity of care and positive health outcomes for the community. Challenges and limitations related to operational role clarity, scopes of practice and leadership.ConclusionHealthcare practitioners were mostly satisfied with the service however challenges caused tension. Change management principles provide a framework to strengthen the effective clinical alignment of the service.

Objectives The aims of the present study were to examine tenants’ experiences of a model of integrated health care and supportive housing and to identify whether integrated health care and supportive housing improved self-reported health and healthcare access. Methods The present study used a mixed-method survey design (n = 75) and qualitative interviews (n = 20) performed between September 2015 and August 2016. Participants were tenants of permanent supportive housing in Brisbane (Qld, Australia). Qualitative data were analysed thematically. Results Integrated health care and supportive housing were resources for tenants to overcome systematic barriers to accessing mainstream health care experienced when homeless. When homeless, people did not have access to resources required to maintain their health. Homelessness meant not having a voice to influence the health care people received; healthcare practitioners treated symptoms of poverty rather than considering how homelessness makes people sick. Integrated healthcare and supportive housing enabled tenants to receive treatment for health problems that were compounded by the barriers to accessing mainstream healthcare that homelessness represented. Conclusions Extending the evidence about housing as a social determinant of health, the present study shows that integrated health care and supportive housing enabled tenants to take control to self-manage their health care. In addition to homelessness directly contributing to ill health, the present study provides evidence of how the experience of homelessness contributes to exclusions from mainstream healthcare. What is known about the topic? People who are homeless experience poor physical and mental health, have unmet health care needs and use disproportionate rates of emergency health services. What does the paper add? The experience of homelessness creates barriers to accessing adequate health care. The provision of onsite multidisciplinary integrated health care in permanent supportive housing enabled illness self-management and greater control over lifestyle, and was associated with self-reported improved health and life satisfaction in formerly homeless tenants. What are the implications for practitioners? Integrated health care and supportive housing for the formerly homeless can improve self-reported health outcomes, enable healthier lifestyle choices and facilitate pathways into more appropriate and effective health care.

Previous research has established that people with severe mental illness and co-occurring substance use disorder leaving prison have multiple and complex health, social and economic challenges. How the criminal justice and mental health systems influence the individual prison-to-community transition experience of this population is less well understood. This paper draws on unique qualitative data from a study of 18 men with co-occurring severe mental illness and substance use disorder leaving prison in Queensland, Australia. A repeat in-depth interview method was used to explore the experiences of the men in prison just prior to release and at two points post-release. Two themes are discussed from analysis of interviews: "risk behaviour and relapse" and "once a criminal always a risk". The findings suggest that individual risk behaviour is structured within a transition risk environment that reduces individual agency, thus facilitating a vicious cycle of release, relapse and reincarceration.

A range of institutional and financial instruments has been used to drive population health outcomes in primary health care in Australia. However, GP sovereignty and the corporatized nature of general practice have generated major challenges. The core of government reform strategy since 1992 has been the creation and financing of Primary HealthCare Organizations (PHCOs), in various forms, to provide an organizational basis to connect GPs to population health performance, and a closer link between the state and GPs. The shift from Divisions of General Practice, the first PHCO, to Medicare Locals (MLs) in 2011 was notable. The latter constructed the object of performance as a raft of broader population health goals, which were framed in terms of accountability to communities through public reporting. Drawing on interviews with Federal government, health professional associations, ML executives and GPs, this paper examines the ways in which such performance instruments were imagined and understood, and areas of contestation. The findings show the different rationalities at play and how different actors seek control of the policy space. They also demonstrate the political precariousness of PHCOs, and the wider difficulty of steering market-based professionals in the achievement of population health objectives.

The post-release period is associated with a range of adverse outcomes for prisoners, especially those with a mental illness. There is limited research into programmes developed to address the needs of this population upon release from custody. This paper describes the demographic, mental health and criminal justice characteristics of a cohort of 63 mentally ill prisoners referred to the Queensland Prison Mental Health Transition Coordination Program in 2010 and 2011, who received time-limited transitional support. Established criminological predictors such as age and substance abuse history were related to first re-incarceration. When a multi-event analysis was performed, a broader range of factors were associated with the time before re-incarceration, including duration of social and recovery support and a diagnosis of psychosis. This study found that among those receiving post-release social and recovery support, longer duration of support is associated with a lower risk of re-incarceration. Other findings of interest include the significant proportion of re-incarcerations for parole breaches. No deaths occurred during the follow-up period.

This special edition of the 'Policy Studies' journal examines performance measurement in social and public policy and public services. Taking a policy instrument perspective the papers in the edition, the articles examine the postitive and negative effects of performance measurement, and what works.

BACKGROUND:The poor physical health of people with severe mental illness (SMI) is often attributed to lifestyle, disease-related medication side effects and disparate provision of healthcare. The complexity and inexact nature of this issue prohibits the identification of a clear and concise causal pathway, which in turn leads to uncertainty and imprecision about the most appropriate action to address the problem. One proposed solution is to integrate care across multiple organisations and sectors through collaborative processes. The objective of this study was to identify collective pathways of action that were consensually developed and which could be initiated by clinicians to improve the physical health of people with severe mental illness.METHODS:Eighteen participants from a service catchment area in Australia were involved in a consensus-building workshop. This resulted in participants identifying and committing to a range of collaborative actions and processes to improve the physical health of people with severe mental illness. Consensus building was combined with an outcome mapping process, which has previously been used to facilitate health system integration. Data from the consensus-building workshop were thematically analysed and used to create an outcome map.RESULTS:Participants identified that accessible, continuous, holistic, consumer-driven, recovery-oriented care was required if improved physical health of people with SMI were to be achieved. However, this all-encompassing care was dependant on a wide-ranging philosophical shift in two areas, namely societal stigma and the dominance of pharmacological approaches to care. Participants believed that this shift was contingent on the attitude and behaviours of healthcare professionals and would require an inclusive, networked approach to care delivery and maximal utilization of existing funding.CONCLUSIONS:Rarely do multiple stakeholders from different sectors within the healthcare system have the opportunity to come together and create a collective vision for improving the health of a specific population in a defined area. We used a consensus building approach to generate solutions, actions and goal statements, which were then used to create a visual map that provided a purpose and signposts for action, thereby maximising the potential for cohesive action across sectors.

Introduction: It is well established that people living with severe mental illness experience shortened average life expectancy resulting in up to 25-30 years of life lost. Despite evidence that indicates there are multiple contributing factors, clinicians commonly believe that the mortality gap is almost solely caused by side effects of psychotropic medication. Furthermore, there is a dearth of research regarding the physical health experience from the perspective of people who are living with severe mental illness. Understanding this experience will be essential if clinicians are to better integrate physical and mental health care for this population. Theory / Method: Semi-structured interviews were conducted with 32 people living with severe mental illness, and who were accessing care and support from public mental health services and / or non-government organizations. Data were thematically analyzed. Results: Overall, participants reported poor physical health that required considerable planning and effort to manage effectively. The mean age of participants was 44.5 years and over half (56%) reported major physical illness. Three overarching themes were identified: “the work of self care”, “the importance of being heard”, and “the importance of social support”. Discussion: Participants struggled to find the motivation for positive health behaviors and illness self-management; however, most were determined to take control of their physical and mental health concerns and become as independent as possible. Despite frequent problems of selfexpression and feelings of anxiety in health care settings, the quality and nature of relationships with health care practitioners was important to participants who valued being listened to and feeling that their concerns were validated. Likewise participants emphasized the role of their social network in terms of managing their mental and physical health. Conclusions: If healthcare practitioners are to improve the integration of physical and mental health care in the population with SMI, it is essential that respectful relationships form the basis of care provision. Second, in line with participants’ expressed desire for independence, promoting and supporting illness self-management is important. Third, individual tailored support particularly aimed at integrating and strengthening informal support networks is indicated. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116603– http://www.ijic.org/ Lessons learned: Although the need for integrated care provision based on respectful relationships seems self-evident, the narratives of participants indicated that they struggled to find clinicians who would listen to them and who respond in ways that protected and promoted physical health. Additionally, although participants recognized the need to interact with a complex health care system, the biographical and social contexts in which they managed their health was not well integrated into care delivery processes. Limitations: Participants in this research needed to be sufficiently well to be able to provide informed consent. Therefore, research findings might not be transferable to those people with severe mental illness who are at different stages of their recovery journey. Future research: Further research is required to ascertain ways in which biographical and social contexts can be better integrated into physical and mental healthcare provision in Australia.

This thesis explores the prison-to-community transition experience after short-term incarceration, from the perspective of men with co-occurring mental illness and substance use disorder in Queensland, Australia. A specific focus was to examine the impact of systems and structures on the individual experience of transition. Prior research has established that people with co-occurring mental illness and substance use are overrepresented in the Australian prisoner population. It is also known that transition from prison to community for the general custodial population is a time of vulnerability, with increased risk of substance use, homelessness, unemployment, reincarceration and post-release death. All of these risks are compounded for prisoners with co-occurring disorders who are also at risk of a range of poor criminal justice outcomes and losing contact with mental health services after release. Review of the literature indicates a tendency for research to focus on recidivism as an outcome and emphasise either individual risk behaviour or social and structural factors influencing prison-to-community transition. Interventions during transition for the current population have traditionally been based on the criminalisation hypothesis, with a focus on increased provision of mental health services in prison and an emphasis on continuity of care in the community. There is a growing recognition in the international literature that the issues are much broader than mental illness; however, there is a lack of clarity as to how to respond to the complex needs of this population. Research exploring the perspective of men with co-occurring severe mental illness and substance use disorder during their prison-to-community transition experience has rarely been undertaken. The conceptual framework developed for this study shifts the emphasis away from recidivism towards recovery and wellbeing through a lens of individual action, but only in the context of the potential for systems and structures to impact on the ability of individuals to exercise agency. A qualitative method was used comprising repeat in-depth interviews with 18 men: within 1 month prior to leaving prison, within 2 weeks post-release and at 3 months post-release. Three themes characterised the transition experience of participants: “hoping against hope”; “adrift in freedom”; and “the slippery slope”. Participants reported leaving the predictable and routine life in prison where they hoped for a better life after release, to an uncertain, unstable and isolated environment in the community, eventually sliding into drug use, chaos and despair. The risk environment framework (Rhodes, 2009) and structuration theory (Giddens, 1984) were employed to understand how participants were caught in a complex dynamic between their individual risk behaviour and broader structural risk environments. This thesis proposes that a web of interrelated factors contributed to participants in the study as “ambivalent agents” who were suspended between the two worlds of prison and community, with a sense of “non-belonging” in either world. They negotiated multiple and competing identities and were ultimately set up to fail in their hope for a normal life in the community by the “structuration” of risk during transition. The findings in this study support previous research that prison mental health services alone are inadequate to meet the needs of this population. There is a need for the review of parole practices for this population, with an emphasis on prevention of incarceration related to non-offending behaviour. In addition, a focus on the provision of comprehensive interventions during prison-to-community transition, such as supported accommodation, assisted employment and other individually tailored social supports, is indicated. These interventions, in combination with a focus on flow through integrated treatment services targeting the needs of short-term prisoners with co-occurring disorders may facilitate recovery and wellbeing in this population, improve continuity of mental health care on return to the community, as well as address criminal justice outcomes. These interventions should be planned as a whole of government response, framed by a mental health recovery approach that fosters belief in the individual for recovery, as well as utilising a collaborative focus on risk in terms of both “a risk” and “at risk” identities.