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Jason Newberry, Senior Researcher

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Building a Recovery Focused Mental Health System: Reflections on Systems Change and Growth in Community Mental Health November 7, 2008 Canadian Innovations in Recovery Conference Kitchener, ON. Jason Newberry, Senior Researcher. Allan Strong, Recovery Education Coordinator. - PowerPoint PPT Presentation
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Building a Recovery Focused Building a Recovery Focused Mental Health System: Mental Health System: Reflections on Systems Change Reflections on Systems Change and Growth in Community and Growth in Community Mental Health Mental Health November 7, 2008 November 7, 2008 Canadian Innovations in Recovery Conference Canadian Innovations in Recovery Conference Kitchener, ON Kitchener, ON Jason Newberry, Senior Researcher Allan Strong, Recovery Education Coordinator
Transcript
Page 1: Jason Newberry, Senior Researcher

Building a Recovery Focused Building a Recovery Focused Mental Health System: Mental Health System: Reflections on Systems Reflections on Systems Change and Growth in Change and Growth in

Community Mental HealthCommunity Mental Health

November 7, 2008November 7, 2008

Canadian Innovations in Recovery ConferenceCanadian Innovations in Recovery Conference

Kitchener, ONKitchener, ONJason Newberry, Senior Researcher

Allan Strong, Recovery Education Coordinator

Page 2: Jason Newberry, Senior Researcher

1. History and background

2. Overview of the training

3. The evaluation process

4. Preliminary findings, learnings, next steps

5. Questions and discussion

Outline of Presentation

Page 3: Jason Newberry, Senior Researcher

• To provide an overview of how the mental health system in our region is changing to be more recovery focused.

• The background of our local context

• The building of a multi-organizational partnership to pursue a recovery focus.

• The development of organizational & community training.

• To describe the evaluation of “recovery focused case management” in the region.

• How consumers contributed to defining outcomes

• The evaluation design and approach

• Findings so far

Our Purpose TodayOur Purpose Today

Page 4: Jason Newberry, Senior Researcher

2005 - Ministry of Health and Long Term care provided funding for the enhancement of case management in the area ( 1.13 million dollars)

Decision about how the money should be allocated must be made by consensus

Planning process involved 3 community agencies, 3 hospitals and an alliance of consumer - survivor groups

Page 5: Jason Newberry, Senior Researcher

Waterloo Regional Homes for Mental Health Grand River Hospital Trellis Mental Health and Developmental

Services Homewood Health Centre Cambridge Memorial Hospital CMHA Grand River Branch The Self Help Alliance

Page 6: Jason Newberry, Senior Researcher

Developed and agreed to a decision making process

Adopted a statement of values and principles to guide our work

Designed services that were “true” to guiding principles and values

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6

Page 7: Jason Newberry, Senior Researcher

What does the word “recovery” mean to you and how would you know when you have recovered?

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Page 8: Jason Newberry, Senior Researcher

Statement was developed by the Self Help Alliance

Statement addresses how the system will look if values and principles of recovery put in place

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8

Page 9: Jason Newberry, Senior Researcher

A recovery oriented mental health and addiction system will :

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

Value and Instill Hope – Recovery can not occur without hope. The system will encourage hope and in doing so will focus on skills and abilities.

Page 10: Jason Newberry, Senior Researcher

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.

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.

Page 11: Jason Newberry, Senior Researcher

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.

From these key values, principles were developed - copies of the document are available

Page 12: Jason Newberry, Senior Researcher

Started from a shared set of values and principles that were developed by consumers. This has not been usually been the case.

Values and principles provide not only a common understanding but also something to hold each other accountable.

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Page 13: Jason Newberry, Senior Researcher

Trip to Ohio - service providers went to Ohio

Self Help Alliance had been developing its own programming based on recovery (independent of service providers)

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Page 14: Jason Newberry, Senior Researcher

A central part of system transformation.

Training of staff in recovery values and principles, and practice.

Training of consumers about recovery and their role in planning

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Consumer and Case Manager Consumer and Case Manager TrainingTraining

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Page 15: Jason Newberry, Senior Researcher

Since April 2006, 30 staff training sessions.

247 staff (case managers, housing staff, ACTT, management).

Since January 2007, 85 consumer training sessions.

Over 250 consumers participated.

15

Consumer and Case Manager Consumer and Case Manager TrainingTraining

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Page 16: Jason Newberry, Senior Researcher

Learning the planning process…

Six steps:1. Ranking & selecting a component 2. Determining the status3. The “MUSE”4. Determining the goal(s)5. Identifying skills & knowledge, developing

an action plan6. Community Resources

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Recovery Action PlanningRecovery Action Planning

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Page 17: Jason Newberry, Senior Researcher

We are a non-profit and independent community-based research organization located in Kitchener, Ontario, Canada.

We engage in diverse streams of work, including applied research and evaluation, needs assessments, systems change initiatives, training & education, facilitation & planning.

Our values emphasize community participation, action, and relevance in the work we do.

Page 18: Jason Newberry, Senior Researcher

CCBR was contracted by the community partners to develop an evaluation framework in reference to new system changes.

The purpose of the evaluation is to….

“To understand how a recovery focus in the Waterloo-Wellington-Dufferin mental health system leads to positive changes for individuals using case-management services”

Building an Evaluation Building an Evaluation FrameworkFramework

Page 19: Jason Newberry, Senior Researcher

CCBR promotes the use of participatory and collaborative research approaches.

In this project, we engaged with consumers in two cities to help us define what the outcomes of the recovery process should be.

We also hired and trained consumer researchers – almost all our data from consumers was collected by our consumer researchers.

Our ProcessOur Process

Page 20: Jason Newberry, Senior Researcher

An important element of our evaluation was the creation of “logic models” – visual diagrams the depict the relationships between CM services and expected outcomes.

CCBR developed a set of logic models through community forums with service users and case managers (separately).

Synthesized the models and fed them back to our steering committee.

The Logic Model ProcessThe Logic Model Process

Page 21: Jason Newberry, Senior Researcher

The logic models helped us gain an understanding of recovery focused outcomes from the perspective of different stakeholders.

Helped us plan the evaluation – what to measure, how, and when.

The Logic Model ProcessThe Logic Model Process

Page 22: Jason Newberry, Senior Researcher

Intensive Case Management Service Standards (in Ontario) provide standards and indicators of best practices. However, they are not focused on outcomes – the actual benefits experienced by consumers. They are largely focused on service delivery.

Example: Where possible, assertive outreach will be offered to

engage potential consumers in their place of choice, considering the safety and security of the consumer and the provider.

Service provision must be managed in a manner that responds to fluctuations/variations in consumer need.

Recovery Outcomes – A Different Recovery Outcomes – A Different EmphasisEmphasis

Page 23: Jason Newberry, Senior Researcher

A few of the Standards (and their indicators) approach and outcome orientation (e.g., consumer satisfaction, perceptions of accessibility).

Our logic model sessions generated a greater range of outcomes that:

add to the Standards, giving a fuller picture of consumer experience.

help us think critically about why we think recovery planning will lead to outcomes desired by consumers.

are recovery focused and quite different from traditional outcomes (e.g., rehospitalization, medication compliance, etc.).

Recovery Outcomes – A Different Recovery Outcomes – A Different EmphasisEmphasis

Page 24: Jason Newberry, Senior Researcher

Planning

Educating consumers

about principles of recovery

Housing, Practical Support, Information, & Advocacy Respectful relationshipsO

utcomes for S

ervice Users (synthesis)

Work with employers to

discuss health issues,

accomm’s, etc

Provide information & advocacy re: services,

benefits, rights

Providing services that are

respectful sensitive to

cultural diversity

Providing practical support & resources

Use of accessible,

plain language

Increased awareness of legal rights re: discrimination, employment,

etc.

Increased feelings of hope

& ability to dream about

recovery

Increased sense of control & choice

regarding their health, lives

A sense of diminished

professional boundaries -- more informal relationship, openness,

Increased feelings of

comfort, trust, & respect for

lived experiences

Ensure open & transparent reciprocal

communication -- honesty in

relationship

Practical assistance in

pursuing career, employment;

finances

Minimal disruption to

your life when having

difficulty

Linking to peer support environment

s

Linking to formal health

supports

Connecting

Involve & educate family

& social networks in

person’s health

Increased connections & sense of support in

community, social &

family life

Creating social

connections with the

community

Ongoing listening

without an agenda

Developing a proactive &

personal plan to prevent crisis

Developing a consumer-driven

& realistic wellness plan about future

goals

Increased self-awareness & recognition of

reasons of health

problems

Feelings of support in

crisis

Developing interpersonal

skills & relationship goals

Communicating & exploring

options

Increased stability in

employment

Increased meaningful work and

volunteering

Increased opportunities, resources & connections

to work & volunteering

Understanding & believing in your personal

goals & dreams Increased

confidence in workers &

system

Greater quality of

life

Increased self esteem & sense of dignity & respect

Feelings of personal

empowerment

People express their identity beyond the

mental health system

Greater self-fufilment &

contentment

Sense of renewal, spirit, joy,

hope

Increased confidence & faith in own decisions,

needs, values

Acting on one’s own

plan for recovery

(practicing options)

Willingness to take risks, to fail, & to learn from it

Improved mental health & stability

Increased skills &

knowledge to pursue

goals

Increased knowledge

of the concept & process of recovery

Greater participation in regular, day-to-day community

life

Sharing the process & success in relationship

to others

Increased financial

security & stability

Increased resources & support in daily living

Case management occurs where

desired

Recovery Focused Case-Management

Logic Model: Outcomes for Service

Users

Improved overall

physical health

Increased choice in accessing

different aspects of system or alternative support

* *

*

*

*

*

*

*

*

Increased movement toward personal goals

Providing support in acquiring & maintaining adequate housing

Improved housing stability

Page 25: Jason Newberry, Senior Researcher

Increased feelings of hope

& ability to dream about

recovery

Understanding & believing in your personal

goals & dreams

Increased confidence in

workers & system

Greater quality of

life

Increased self esteem & sense of dignity & respect

Feelings of personal

empowerment

People express their identity beyond the

mental health system

Greater self-fufilment &

contentment

Sense of renewal, spirit, joy,

hope

Increased confidence & faith in own decisions,

needs, values

Acting on one’s own

plan for recovery

(practicing options)

Willingness to take risks, to fail, & to

learn from it

Improved mental health & stability

Greater participation in regular, day-

to-day community life

Sharing the process & success in relationship

to others

*

*

Increased movement toward personal goals

KEY RECOVERY-FOCUSED OUTCOMES

An emphasis on hope and dreaming, risk-taking and action, confidence in the system, and decision making leading to a cycle of recovery.

Page 26: Jason Newberry, Senior Researcher

How do we get there…?How do we get there…?Planning

Educating consumers

about principles of recovery

Developing a proactive &

personal plan to prevent crisis

Developing a consumer-driven

& realistic wellness plan about future

goals

Increased self-awareness & recognition of

reasons of health

problems

Feelings of support in

crisis

Developing interpersonal

skills & relationship goals

Communicating & exploring

options

Increased skills &

knowledge to pursue

goals

Increased knowledge

of the concept & process of recovery

*

Respectful relationships

Providing services that are

respectful sensitive to

cultural diversity

Use of accessible,

plain language

Increased sense of control & choice regarding their

health, lives

A sense of diminished

professional boundaries -- more

informal relationship, openness,

Increased feelings of

comfort, trust, & respect for lived

experiences

Ensure open & transparent reciprocal

communication --honesty in

relationship

Ongoing listening without

an agenda

Case management occurs where

desired

*

*

Page 27: Jason Newberry, Senior Researcher

• How and to what extent is a recovery-focused approach to case management helping people gain the skills and knowledge they need to develop their wellness plan and pursue their own goals?

• Are people beginning to understand the idea of recovery and what it can mean for their own goals?

• How and to what extent is recovery focused approach to case management helping to alter the traditional relationships between case managers and people they support?

Priority Outcomes and QuestionsPriority Outcomes and QuestionsService User ModelService User Model

Page 28: Jason Newberry, Senior Researcher

• What is being done to ensure a reciprocal, honest and open relationships between case management and people?

• To what extent are people feeling an increased sense of control and choice regarding their health and lives?

• 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?

Page 29: Jason Newberry, Senior Researcher

• What are the experiences, successes, & challenges of the organizations within partnership in building a collaborative, system wide approach to recovery-focused case management?

• What is the impact of the training on the knowledge and skills of case managers to promote a recovery focus What are the successes and challenges?

• Is a recovery focus apparent in the practice? Are there attitudinal or organizational barriers?

Priority Outcomes and QuestionsPriority Outcomes and QuestionsService/System ModelService/System Model

Page 30: Jason Newberry, Senior Researcher

Design & Methodology – Service UsersDesign & Methodology – Service Users

1.Service User Survey Interview

• A mix of demographics, existing & customized scales focused on outcomes, and qualitative questions focused on service use.

• This is our main “pre-post” to examine change.

• 86 participants

2.Service User Qualitative Interviews

• Qualitative interviews to explore ideas about recovery, its relationship to case management, and expected outcomes.

• 9 participants (4 Well.-Duff.; 5 Wat.Reg.)

Page 31: Jason Newberry, Senior Researcher

DRAFT copy – not to be used without permission

Design & Methodology – Case Design & Methodology – Case ManagersManagers

3.Case Manager Online Survey

• A combination of custom scale items and open-ended questions to assess:

• the implementation of the recovery training

• use of the recovery action plan tool in practice

• perceptions and attitudes regarding recovery values and practice.

• 57 case managers completed the survey

4.Case Manager Focus Group

• To gain a deeper understanding of the survey findings. 10 case managers participated.

Page 32: Jason Newberry, Senior Researcher

DRAFT copy – not to be used without permission

Design & Methodology – ManagersDesign & Methodology – Managers

5.Management Key Informant Interviews

• Interviews with members of the committee to gain insight regarding…

• building a multi-organizational partnership

• creating system wide service delivery policies

• Successes & challenges in translating policy into practice

• Future initiatives of the system partnership

• 5 key informant interviews were conducted.

Page 33: Jason Newberry, Senior Researcher

Feedback on the Case Manager Feedback on the Case Manager TrainingTraining

•Training has been well-received and appreciated by most case managers.

• There was a desire for more training with more practical dialogue, exchange and discussion.

• Difficulties with the training, when cited, would appear to linked more so to “difficulty with the tool”.

Page 34: Jason Newberry, Senior Researcher

Attitudes & PerceptionsAttitudes & Perceptions

• There was very strong support for the principles and values of recovery (80%+ above the midpoint of the scale).

• CMs tended to believe that their home organization was doing a good job of incorporating principles and values of recovery – but the system had a long way to go.

Page 35: Jason Newberry, Senior Researcher

Use of the Recovery Planning ToolUse of the Recovery Planning Tool

• 41% reported using the tool; 18% with some modifications; 26% were not using the tool

• 66% were engaged in 1-5 plans; 23% in 6-10 plans; 11% in 10 or more plans

• Explanations for modifying the tool ranged from simple changes to make it a bit easier to significant changes (and abridged summary form).

From the focus group:

“For some clients the smallest amount of paperwork can be intimidating. With 1 hour of flipping back and forth with this cumbersome book, it’s pretty intimidating. Clients say; “I don’t want to go there”. When in fact they have a vision of what recovery is but the book and paperwork in front of them prevents them from moving forward because they are frightened by it.” – focus group participant

Page 36: Jason Newberry, Senior Researcher

RE: the Recovery Planning Tool & RE: the Recovery Planning Tool & ProcessProcess

• The tool/process was viewed by CMs as difficult or confusing for some service users and CMs alike.

• 44% of CM agreed that many service users are not ready to go through the process; 37% believed the process was not suitable for many service users.

• We also heard in some cases the tool wasn’t being used with service users – information was being gathered by CMs and then the tool was being filled out later.

• This represents a lack of engagement with the recovery plan process.

Page 37: Jason Newberry, Senior Researcher

RE: the Recovery Planning Tool & RE: the Recovery Planning Tool & ProcessProcess

• A very positive finding was that case managers, system-wide, have been truly engaging with the tool to try to improve it and have initiated processes to make it more user-friendly and accessible.

• Case managers also reported feeling supported by their supervisors and organizations in the area of recovery planning.

Page 38: Jason Newberry, Senior Researcher

Case Managers’ Perspectives on Case Managers’ Perspectives on OutcomesOutcomes

• At this point, there is little evidence that relationships between CMs and services users (from CMs perspective) has improved, although a majority of CMs cite “improved communication”.

• Perceptions of service user outcomes were only moderate (mean between 4 and 5.5 on a 7-point scale) (see Table 12, p. 38)

• This is baseline data, and is expected. It could also be a function of mental averaging of CMs.

• We will be following up on this data in the next phase.

Page 39: Jason Newberry, Senior Researcher

Service User Evaluation – Service User Evaluation – DemographicsDemographics

• 86 service users participated86 service users participated

• 57% were male, 43% female57% were male, 43% female

• CM service use ranged from .5 to 39 years,CM service use ranged from .5 to 39 years,

• Average length was 11 years and 6 years for Average length was 11 years and 6 years for their current agencytheir current agency

• 55% had completed H.S.; 21% had 55% had completed H.S.; 21% had college/university; 24% had primary school.college/university; 24% had primary school.Age category Frequency Percentage

Less than 30 years 8 9.330-39 18 20.940-49 28 32.650-59 23 26.760years or older 9 10.5Total 86 100

Page 40: Jason Newberry, Senior Researcher

Service User Evaluation – Baseline Service User Evaluation – Baseline OutcomesOutcomes

Our survey assessed:

• Community Integration

• Social Support

• Knowledge of Recovery Concept and Own Goals

• Hope and Dreaming

• Risk-taking, Action and Confidence

• Relationships with Staff

• Independence and Interdependence

• Control and Choice (empowerment)

Page 41: Jason Newberry, Senior Researcher

Service User Evaluation – Baseline Service User Evaluation – Baseline OutcomesOutcomes

• This is baseline data. We do not expect “good outcomes”, but a range of responses and moderate or low averages.

• We appear to have “good measures” – they were internally consistent & reliable, there was lots of variation, there were no “ceiling effects”.

• The measures intercorrelated in ways that made theoretical sense:

• Better relationships with staff are associated with high MHR scores.

• Sense of control is associated with MHR scores.

• Greater interdependence, community integration, and social support are associated MHR scores.

Page 42: Jason Newberry, Senior Researcher

Increased feelings of hope

& ability to dream about

recovery

Increased sense of control &

choice regarding their health,

lives

Increased confidence & faith in own decisions,

needs, values

Acting on one’s own plan for recovery

(practicing options)

Willingness to take

risks, to fail, & to learn

from it

Increased skills &

knowledge to pursue

goals

Increased knowledge

of the concept & process of recovery

Increased feelings of trust,

comfort, and respect for lived

experienceA sense of diminished professional

boundaries, informal relationships

Increased confidence in workers & the

system

CONTROLSTAFF RELATIONSHIPS

ELEMENTS OF RECOVERY

Page 43: Jason Newberry, Senior Researcher

Increased feelings of hope

& ability to dream about

recovery

Increased sense of control &

choice regarding their health,

lives

Increased confidence & faith in own decisions,

needs, values

Acting on one’s own plan for recovery

(practicing options)

Willingness to take

risks, to fail, & to learn

from it

Increased skills &

knowledge to pursue

goals

Increased knowledge

of the concept & process of recovery

Increased connections & sense

of support in community, social &

family life

Greater participation in regular, day-to-day community

life

Sharing the process & success in relationship

to others

ELEMENTS OF RECOVERY

SOCIAL SUPPORT & COMMUNITY INTEGRATION

Page 44: Jason Newberry, Senior Researcher

Re: Community integration…

“…without the Recovery Plan I don’t think I would have made it to go here or to go there. For example meeting, coming out from the house, catching the

bus, coming to meet people is a very good thing for me. Talking to people where I know that I can

discuss about my problems.” – service user interview

Re: Moving towards recovery...

“My case manager put me in a state of mind where I would look forward to the future rather than “just sit

on ODSP.” She helps me with self esteem and problem solving. I have confidence now that I can

go back to work. My case manager is very supportive and empathetic.” – from the survey

Page 45: Jason Newberry, Senior Researcher

Re: the “Cycle of Recovery” – risk, action, confidence

“Over time my case manager said: `why don’t you try certain things to see if…go step-by step and see how you might do’….I’m hopeful for achieving my

goals considering my past experience in the last 5 or 6 years. I went to school and took 10 courses over 5 years and I did fairly well in all of them. That gives me the motivation then to want to continue to try

and do something more if at all possible.” - Service user interview

Re: Recovery planning...

“My case manager put me in a state of mind where I would look forward to the future rather than “just sit

on ODSP.” She helps me with self esteem and problem solving. I have confidence now that I can

go back to work. My case manager is very supportive and empathetic.” – from the survey

Page 46: Jason Newberry, Senior Researcher

Re: Relationships

“It's always very important to me in any relationship that it be a good relationship. However, some of the workers I've had in the past have not respected the fact that if they constantly cancel appointments, if they say they're going to do something and then

they don't do it, that affects me. That to me is very difficult….I'm available when I'm supposed to be,

and I'm doing that I'm supposed to do and just like with anything I think that that needs to be mutual.”

VS.

“(In a good relationship) I feel more empowered. I feel like I'm – I've had a good appointment, we've

come up with some really good solutions, I'm going to try this and I'm more motivated to keep going during those really tough times.” – service user

interview

Page 47: Jason Newberry, Senior Researcher

Participation in the Recovery ProcessParticipation in the Recovery Process

Life Area

With recovery plan (N= 56; 65%)

Without recovery plan (N= 30; 35%)

Number % Number %

Community integration

41 73.2% 11 36.7%

Work/meaningful activity

39 69.6% 14 46.7%

Access to resources 38 67.9% 15 50.0%

Power and control 36 64.3% 10 33.3%

Clinical care 36 64.3% 14 46.7%

Family support 34 60.7% 14 46.7%

Peer support/relations

30 53.6% 11 36.7%

Spirituality 27 48.2% 6 20.0%

Education 25 44.6% 9 30.0%

Stigma 21 37.5% 11 36.7%

Page 48: Jason Newberry, Senior Researcher

Participation in the Recovery ProcessParticipation in the Recovery Process

Among those who had a plan in process:Among those who had a plan in process:

• 56% had a copy of their plan, 44% did not56% had a copy of their plan, 44% did not

Of those with a copy:Of those with a copy:

• 12 (39%) had not consulted their plans12 (39%) had not consulted their plans

• 14 (45%) did so only “rarely” or 14 (45%) did so only “rarely” or “sometimes”“sometimes”

• 5 (16%) did so “often”5 (16%) did so “often”

This finding is an area that deserves This finding is an area that deserves attention.attention.

Page 49: Jason Newberry, Senior Researcher

Future Evaluation – Phase II Future Evaluation – Phase II

• Re-administering the service user survey Re-administering the service user survey as a time 2 follow up, to compare to as a time 2 follow up, to compare to baseline.baseline.

• Re-administering selected pieces of the Re-administering selected pieces of the case manager survey to compare changes case manager survey to compare changes over time to practices.over time to practices.

• Recommend collecting more qualitative Recommend collecting more qualitative data from a more diverse cross-section of data from a more diverse cross-section of service users.service users.

These three activities comprise the main These three activities comprise the main components of the next evaluation phase. components of the next evaluation phase.

Questions, Comments?Questions, Comments?

Page 50: Jason Newberry, Senior Researcher

Think about the Saskatchewan experience…

What are the greatest challenges to pursuing a recovery-focused system in your region (province, city, town, community)?

How can they be overcome?

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Open Discussion…Open Discussion…

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