Sample Characteristics
All client participants (n=12) were female caregivers. A quarter were grandmothers who had assumed responsibility for a child under kinship care and the remainder were birth parents. Almost half the client participants (5/12) identified as single parents. Almost all client participants experienced mental health issues (11/12) and significant relationship difficulties (11/12).
Service provider participants (n=21) came from a range of backgrounds, including medicine/nursing (n=7), education (n=2), specialist case workers (n=6) and social work (n=6). Four service providers were HHAN staff. However, the majority (n=17) were stakeholders from HHAN partner organisations, including General Practice (n=4), New South Wales (NSW) Family and Community Services (FACS) (n=4), the NSW Department of Education (n=2) and non-government organisations (NGO) and charities (n=5).
CMO Configurations
Interview data highlighted two process mechanisms operating within HHAN: engagement of vulnerable clients; and integrating care. Relational and operational mechanisms operated within these two process mechanisms and their related CMO configurations were identified. Contextual factors were categorised into Layder’s contextual levels, as described above.
Process Mechanism 1: Engagement of Vulnerable Clients
In order to improve the care of vulnerable clients, one must work in partnership with them. The care coordination aspect of HHAN revolved around the ability of the care-coordinators to engage this group and gain their trust. Five relational mechanisms related to engagement of vulnerable clients were identified.
Relational Mechanism 1: Leveraging other relationships.
The CMO mechanisms of the theme are summarised in Table 1.
Level of context (Layder 1993)
|
Contextual factors
|
Relational Mechanisms
|
Outcomes
|
Self-identity
|
Presence of domestic violence
Cultural expectations of the role of women
Reluctance to engage with services
|
Leveraging off pre-existing relationships to provide wrap-around care and engage clients with additional services
|
Clients’ improved access to care and engagement with a broader range of services
Enhancement of a service’s reputation within families or communities
|
Situated Activity
|
Access to supportive family and social networks
|
Intermediate Level
|
Level of trust between:
-client and index case worker
-client and client’s friend/family member
-client’s friend/family member and case worker
-professionals involved
Whether client consent to refer to other services can be obtained
|
Table 1: CMO configurations for Relational Mechanism 1 “Leveraging other relationships”
The concept of “wrap-around care” was a key design element of the programme theory (13) operating at the contextual levels of Self (identity/individual experience), Situated Activity (face-to-face activity) and Intermediate (service organisation) levels. HHAN CCs often tried to engage with the spouse, children and grandparents to provide support to the whole family.
The importance of wrap-around care was particularly evident when care-coordinators were seeking to engage with large kinship networks. Establishment of trust within families had a ripple effect, and could encourage other family and community members to seek out help from the HHAN team or associated services. This leveraging of existing relationships occurred both within family networks and within communities as a relational mechanism underlying effective wrap-around care.
“… the amount of people that walk in here and say such and such told me to come and see you….Because the word of mouth is being positive. So it's reputation and then there’s trust”. (Service provider)
Contextual factors at the level of Self, however, also influenced mechanisms and outcomes. The flip-side of leveraging off relationships with others was that an adverse interaction between a client or family and a care-coordinator could have far-reaching effects on trust across a wide social network. There were instances where it was difficult or impossible to engage others within the family and even direct conflict between care-coordinator and contacts. This was a particular issue in families affected by domestic violence or from cultures where women were devalued and the care-coordinator was female.
“I’m doing it to make a difference for those children and maybe to empower her…. To see that it isn’t ok for her kids but then you know he [her husband] will totally, totally hate us for that. We certainly don’t have his agreement for any [of her care] goals. And he won’t even agree to meet”. (HHAN CC)
Wrap-around care could also operate through leveraging collaborations between service providers, at the Intermediate Level. Relationships with one professional could act as a conduit to engaging clients with other services. Sometimes the trusted professional would act as a link between their client and other services, directly referring them on. At other times, they would consult other services, but continue as the sole person working face to face with the client. These leveraging approaches enhanced client outcomes by improving their access to a broader range of services without the need for clients to build trust with new workers.
Several professionals raised concerns about maintaining confidentiality when collaborating with other services, and obtaining consent from clients. This was an important contextual factor with the potential to mediate the impact of leveraging as a relational mechanism. NSW Child Protection Legislation (Section 16A, Children and Young Persons (Care and Protection) Act 1998), allows for information sharing between agencies without client consent, where there are concerns about the welfare of a child. In the current study, however, neither professionals nor clients gave examples of where they had experienced difficulties or complaints related to privacy.
Relational Mechanism 2: Meeting the client on their own terms.
The operation of this relational mechanism was examined at the levels of Self, Situated Activity and Intermediate contextual levels.
Level of context (Layder 1993)
|
Contextual factors
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Relational Mechanisms
|
Outcomes
|
Self-identity
|
Presence of intergenerational trauma
|
Flexible service delivery by care coordinators
Client priorities are reflected in initial goal setting
|
Clients’ needs are met
Enhanced client engagement
Staff stress and burnout prevented
|
Situated Activity
|
Extent to which flexible service delivery is built into the programme
Level of case worker autonomy in selecting approach
Level of case worker willingness, patience and confidence to deviate from standard practice
Existence of Occupational Health and Safety concerns
|
Intermediate Level
|
Availability of other services that can assist with providing care and support CC’s role
Level of trust between service providers
|
Table 2: CMO configurations for Relational Mechanism 2 “Meeting the client on their own terms”
Attending an appointment in an “institution” could be intimidating for somebody with low literacy or self-confidence, especially if they had had adverse experiences with authorities in the past. This was articulated by one educator working in a deprived social housing estate.
“Their priority is to help their child but they can’t actually get them to the Dental Hospital, even though it’s close, because they’re having a really hard time and they need support… some of them need hand-holding and confidence is a huge problem; we see parents when they first come here, they’re quite withdrawn and hollow and it’s like an institution…”
Meeting the client on their own terms through flexible service delivery was a crucial relational mechanism promoting engagement (see Table 2) that came up frequently during interviews with service providers and clients. Care-coordinators described adopting various non-standard interventions to promote engagement, operating primarily at the Situated Activity contextual level. Care-coordinators were often required to make themselves available at varied times and places, using the means of communication that was most acceptable to the client.
Genuinely listening to clients’ concerns and prioritising them in goal setting, particularly in the initial phase of involvement, was another important mechanism. By focusing on the client’s most pressing need, care-coordinators could build trust and create opportunities to subsequently work on other issues that they considered important. The success of this approach, however, hinged on care-coordinators’ willingness to be patient and flexible.
The down side of flexible service provision was that it could take its toll on care-coordinators, some of whom displayed evidence of burnout. Staff turnover could have a major impact on client outcomes, particularly continuity of care, trust and engagement.
“One of my patients who’s really difficult was doing great when he had a case worker…. Four months later he just DNAs [does not attend appointments] again, I can’t get hold of him and it’s because the case worker changed… I would have loved them to call me and let me know… then the patient ends up in hospital and then it can take six months to recover from those sorts of setbacks”. (GP)
At times, flexible service delivery was dependent on contextual factors at the Intermediate Level, such as the availability of other suitable services to assist clients.
“There can be services but a lot of them are at capacity… so we are often holding them”. (HHAN CC)
The intended role of HHAN care-coordinators was putting services and clients in touch with one another and arranging care, before gradually reducing intensity of involvement. This model of care proved difficult at times due to tensions between “care coordination” and “case management” roles. Care-coordinators were often required to be a lot more “hands on” than anticipated. Having built a relationship with the client, it could be difficult to step back (practically and emotionally). In several instances there were no services to take over care.
“I don’t see it’s possible to step away. So many of these clients have had no one to trust … I think it’s very important for these clients to know that there is someone out there who is stable, who isn’t judging them for whatever situation comes up next but simply helps them to navigate whatever challenge has come up next”. (HHAN CC)
Relational Mechanism 3: Building Trust.
CMO configurations for building trust with clients are shown in Table 3.
Level of context (Layder 1993)
|
Contextual factors
|
Relational Mechanisms
|
Outcomes
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Self-identity
|
Whether client had had a child removed from their care
Level of distrust of authority
Importance of making changes to retain custody to the client
|
CC likeable and approachable: “a safe person”
|
Level of client engagement
Level of CC burnout
|
Situated Activity
|
Presence of child protection concerns
|
Intermediate Level
|
Relationship between CC and Family and Community Services
|
Table 3: CMO configurations for Relational Mechanism 3, “Building Trust”
Many clients indicated that care-coordinators needed to be likeable, approachable and a “safe person”. Without these qualities, a relationship of trust would not be achieved. Care-coordinators wore casual clothing, used informal language and avoided jargon to erode the notion of a power base and maintain approachability.
A key challenge to building trust was that several clients had previous or ongoing involvement with child protection services. Although not directly involved, care-coordinators remained bound by mandatory reporting obligations. In Australia, all health staff are required by law to report suspected cases of child abuse or neglect to the relevant government authority. In NSW, mandatory reporting is regulated by the Children and Young Persons (Care and Protection) Act 1998 (the Care Act) (23) and mandatory reporters are guided by the NSW Mandatory Reporter Guide. Care-coordinators had to juggle their interactions with child welfare workers and the client and, at times, this resulted in conflict. One client disengaged as a result of child protection concerns reported by a care-coordinator.
Relational Mechanism 4: Engaging by demonstrating effectiveness of the partnership.
CMO configurations related to care-coordinators demonstrating effectiveness to clients are shown in Table 4.
Level of context (Layder 1993)
|
Contextual factors
|
Relational Mechanisms
|
Outcomes
|
Self-identity
|
Clients’ past experiences with services and willingness to give CC a chance
Complexity of client problems
|
CCs demonstrate effectiveness of partnership
|
Client engagement in HHAN
Enhanced outcomes for client and family
Prevention of CC burnout
|
Situated Activity
|
Level of CC knowledge, experience and persistence in effecting positive change for client
|
Intermediate Level
|
CC’s reliance on other services to provide care, and their capacity to meet the client’s needs
|
Table 4: CMO configurations for Relational Mechanism 4, “Engaging by demonstrating effectiveness of the partnership”
Clients frequently reported that trust in their care-coordinator was primarily based on the practical benefits that stemmed from engaging with the worker, such as being successfully rehoused, or accessing financial support. A number of Situated Activity level contextual factors impacted, however, on whether or not care-coordinators could demonstrate their effectiveness. For example, clients frequently spoke of the importance of confidence in their care-coordinator’s skills and experience. All four HHAN care-coordinators were highly experienced nurses and social workers. Data suggested that clients may have been less likely to give a care-coordinator a chance to prove their worth if they were younger or less experienced.
Self-level contexts interacted with those operating at the Situated Activity level. In many cases the client’s problems were complex and unpredictable. In this context, care-coordinators needed to have realistic expectations of outcomes, and be adept at navigating which problems could be solved.
“Literally every week it’s a major crisis…who’s broken into the house, who’s lost what, who’s hit who this week… it’s just like a horror movie for some of these people”. (Stakeholder)
As discussed previously, Intermediate level factors such as the availability of other services, shaped the operation of relational mechanisms and outcomes. In addition, when care-coordinators were dependent on other services to assist the client, and the intervention was unsuccessful, the relationship with the client and care-coordinator could be jeopardised.
Relational Mechanism 5: Making clients feel valued and empowered.
Making clients feel valued and empowered was a strong theme that emerged as another relational mechanism associated with HHAN’s effectiveness (see Table 5), operating at the level of Self and Situated Activity.
Level of context (Layder 1993)
|
Contextual factors
|
Relational Mechanisms
|
Outcomes
|
Self-identity
|
Level of client confidence given history and current social situation
Level of client motivation
Client’s view of authority figures
|
CC demonstrates valuing of client by advocacy and “going beyond the call of duty”
Promoting client independence
|
Client empowerment
Enhancement of client outcomes
Prevention of CC burnout
|
Situated Activity
|
Level of responsibility CC gives to client
|
Table 5: CMO configurations for Relational Mechanism 5, “Making the client feel valued and empowered”
Promoting client independence was a key relational mechanism integral to client empowerment.
“The aim is hopefully that we’re not babysitting families… we’re trying to promote independence so they feel comfortable, connected with community and health”. (HHAN CC)
All care-coordinators described taking active measures to avoid creating dependency in their clients such as intentionally making clients call to make appointments for themselves. Wherever possible, they took on a ‘guiding’ rather than a ‘doing’ role.
“She’s given me some guidance, I’m familiar with where I should go now and what needs to happen … I’m comfortable doing so”. (Client)
Client dependency could result in care-coordinators feeling isolated. In the case of more challenging clients, dependency could also lead to staff burn out.
“For most of my clients it’s taken so long to find someone who fits their needs because there’s such a broad spectrum that somebody requires, the clients don’t let go. I’m still in there, they’re still ringing me, they’re still having this relationship with me where they will tell me about the ongoing problems. I think that’s a good thing because they’re still opening boxes for me and I’m finding other things that are still layer upon layer… but it’s also really challenging because you don’t kind of get a break with these clients. You don’t have the easy clients which offset the more challenging clients; they’re all challenging”. (HHAN CC)
Although no adverse effects of burnout were reported by clients, it was anticipated that care-coordinator burnout and stress might threaten the relationship with the client and the longevity of the programme.
“I really struggled within this job for quite a period of time because it was nothing like I thought it would be and I felt quite unsupported in the transition as I actually developed my own sense of what my role within the team was”. (HHAN CC)
Process Mechanism 2: Integrating care
The second process mechanism behind the success of the HHAN programme was integrating care. Four operational mechanisms were identified, based on themes arising in the interview data.
Operational mechanism 1: Knowledge Transfer Activities
As discussed, the HHAN intervention was designed to build capacity for interagency collaboration. Interview data highlighted that key operational mechanisms for enhancing staff collaboration related to knowledge transfer activities (see Table 6), functioning at the contextual levels of Situated Activity and Intermediate Level service organisation.
Level of context (Layder 1993)
|
Contextual factors
|
Operational Mechanisms
|
Outcomes
|
Situated Activity
|
Physical proximity of collaborating staff
Willingness of CC to work with others
|
Knowledge transfer between staff working together
Shared goals, language and professional learning activities among collaborating interagency staff.
Co-location of service providers
|
Faster and more appropriate resolution of client problems
Enhanced CC decision-making and work satisfaction
Reduced conflict between agencies
Capacity to enhance outcomes
Relationship building among workers
|
Intermediate Level
|
Existing relationship between CC and other staff in inter-disciplinary and inter-agency teams
Links between CC and other services
Willingness of staff to share knowledge
|
Table 6: CMO configurations for Operational Mechanism 1, “Knowledge Transfer Activities”
HHAN adopted a model of staff collaboration and inclusivity in which professional learning pathways and training opportunities were created and shared across different disciplines and organisations. Knowledge transfer activities and shared learning were both formal and informal, including multidisciplinary meetings, clinics and training sessions. Professional partners focused on shared goals and language in order to further their projects and avoid conflict.
“We are certainly taking this global approach. This brings global problems and knowing how to support both clients and the staff through this process has been challenging”. (HHAN CC)
“We’ve all grown as a result of it and I think we’ve become less protective or defensive of our roles as a nurse or a social worker, you know, I feel more comfortable with being part social worker now despite the fact I’ve had no formal training in it”. (HHAN CC)
Service providers almost universally described co-location with other services as extremely helpful for integrating care. Co-location promoted regular informal knowledge transfer and offered opportunities for enhanced collaboration.
“Instead of doing it by myself and having to make calls, I have access to learned professionals in different areas such as legal, drug health, youth services, health and family services, paediatrics, all surrounding and supporting me.... you could have a genuine real time collaboration within minutes of engaging with a client and you could also wrap- supports around a client in real time, that's the biggest difference. I have found that better outcomes for the client and the actual timing is just so much quicker …. Now that I have access to my own advice, my decisions are far better”. (Stakeholder)
Operational mechanism 2: Implementing structural change
CMO configurations related to implementing structural change are shown in Table 7.
Level of context (Layder 1993)
|
Contextual factors
|
Operational Mechanisms
|
Outcomes
|
Situated activity
|
Level of insight or awareness of difficulties faced by other service providers
Service provider resistance to collaboration
|
“Systems thinking” among professionals
The desire to bring about positive change
Creative problem solving
Actively seeking to connect with unknown service providers
|
Strengthening and simplifying of referral processes
Enhanced staff knowledge of other services’ roles
Shared training opportunities for staff from different agencies
|
Intermediate Level
|
Acknowledgement by professionals of systemic barriers to care
Extent of buy-in from managers regarding integrated care
Siloing of funding sources
|
Table 7: CMO configurations for Operational Mechanism 2, “Implementing structural change”
HHAN challenged traditional welfare provision to disadvantaged families. Siloed funding and management structures, and resistance to collaboration among service providers, were key contextual factors influencing the mechanisms related to integrated care.
Simplifying referral processes resulted in increased outcomes and satisfaction for both clients and stakeholders. The HHAN programme director and manager required support from partners and stakeholders for this to occur. In some instances, there was a lack of understanding of the roles of other professionals and an inability to see benefits of collaboration.
“There has been a lot of shakeup…I think even the importance of highlighting those silos has been really important and those conversations but...I know how difficult that change can be, culture change and how people are quite fearful of those changes… that pushback can be quite strong”. (Stakeholder)
In order to promote care integration and structural change, traditional power bases had to be challenged, in a respectful and constructive manner, ensuring all professional opinions were respected.
“I really do believe…it’s bringing all the agencies together to brainstorm how we’re going to and, and listening to people’s expertise around the table”. (Stakeholder)
Operational Mechanism 3: Fostering Mutual Respect and Trust.
Fostering mutual respect and trust between staff was key to achieving HHAN’s objectives (see Table 8) and related to Self, Situated Activity and Intermediate Levels contextual factors.
Level of context (Layder 1993)
|
Contextual factors
|
Operational Mechanisms
|
Outcomes
|
Self
|
Attitudes towards collaboration among staff
Service provider knowledge of other services’ roles
|
Challenging of traditional power bases
Guidelines and formal agreements to build consensus
Advocacy for, and validation of, other professionals or agencies
|
Enhancement of inter-agency relationships
Potential for shifting staff attitudes towards collaboration through positive experiences
Increased likelihood of working together in the future
|
Situated Activity
|
Differing world views and personality clashes
Physical proximity of staff working together
Extent to which HHAN were likeable, available and persistent
|
Intermediate Level
|
Management support for collaboration
|
Table 9: Operational Mechanism 3, “Fostering mutual respect and trust”
Inter-agency guidelines and agreements were sometimes used to build consensus between staff and agencies. HHAN was also able to empower some services by validating them in the eyes of others.
“I’ve been knocking on one organisation’s door for a very long time… a great thing about HHAN is that if there’s been an introduction there so they’ve helped me link to that organisation…. Because health [HHAN] is there standing beside us saying we want you there to help”. (Stakeholder)
HHAN staff made themselves approachable and available, and were persistent in attempting to develop and strengthen relationships, even in the face of inevitable conflicts. The process of shared learning and team troubleshooting in relation to difficult clients, served as opportunities to foster trust and respect between service providers.
“The HHAN director is always available … I think that willingness, that relationship and the respect for the services I think is what pushes this project along in my view”. (Stakeholder)
The HHAN team and stakeholders described many contextual factors influencing the extent to which respect and trust could be fostered among service providers. Different organisations and individuals often had opposing worldviews. In some instances, personality clashes between individuals could have a particularly destructive flow-on effect.
“I know she has felt that I shouldn’t be at the meetings… I heard that an email was sent saying it had been decided that I should not attend those meetings. [it] really disrespects me as a person and as a professional”. (HHAN CC)
Operational Mechanism 4: Cultivating a culture of faith in positive change
A crucial operational mechanism operating in the HHAN initiative was a shared believe among staff that the programme could work (see Table 10).
Level of context (Layder 1993)
|
Contextual factors
|
Operational Mechanisms
|
Outcomes
|
Self-identity
|
Staff burnout and jadedness
|
Cultivating faith in positive change related to integrated care
Role modelling collaboration
“Selling” the benefits of HHAN through advocacy
Experiential learning
Creative problem solving
|
Enhanced buy-in by staff and agencies
Enhanced resources for implementation
Quality of staff involved
Level of staff turnover
|
Situated Activity
|
Visibility of benefits of collaboration
Realistic expectations of time frames of change
|
Intermediate
|
Presence of inspiring transformational leadership
|
Table 10: CMO configurations for Operational Mechanism 4, “Cultivating a culture of faith in positive change”
In order to create sustainable positive change in relation to integrating care, HHAN staff had to change cultures both within and between organisations. Service providers had to role model collaboration and become advocates for the HHAN programme in the hope that they would win over other hearts and minds. There was evidence of transformational leadership at all levels.
Service providers sometimes reported that “selling” HHAN to other services could be challenging unless they could demonstrate the positive benefits of the initiative.
“It seems that it wasn’t a very easy exercise to get people to agree to what you are doing… there was an awful lot of explanation of who we are”. (HHAN CC)
In the case of complex interventions like HHAN, it could be difficult to clearly demonstrate benefits and change occurs over a long period of time. As one care-coordinator noted:
“We’re learning as we go. I do think we’re making a difference in people’s lives. Sometimes the case studies show you that much more”.
The risk of workers becoming burnt out and jaded posed a threat to the project. The provision of ongoing practical and moral support to all staff was therefore crucial.
Moreover, the project was large and ambitious. Different parties seemed to have different expectations of what HHAN would be able to achieve and over what time frame. In some instances this mismatch of expectations resulted in disappointment and conflict.
“I just had a hope that this time it would move a bit quicker. I don’t think you can actually judge it yet. I think to try and judge it now is too soon. Honest to goodness it needs more funding and it needs a longer period of time… I don’t know what people were expecting from HHAN either. If they think you’re going to get dramatic change in an instant then you know it never it works like that”. (Stakeholder from NGO)