Does fundamentally altering the staffing of clinical rehabilitation services impact their function?

Dear Editor,

Australia is introducing novel staffing approaches to public mental health services, including increased availability of Peer Support Workers (PSWs) and Non-Government Organisation (NGO) partnerships.^1,2 While consistent with contemporary Australian mental health policy frameworks, these changes have been subject to limited research. ³ Transitional residential rehabilitation services, such as the Community Care Units (CCUs), have been a focus of these staffing innovations.

Until 2014, all Queensland CCUs operated a ‘clinical staffing’ model where most staff were directly employed health professionals, with nurses predominating. Since then, most new CCUs have operated integrated staffing or NGO partnership approaches (see Supplementary Tables 1-2). Under the ‘integrated’ approach, PSWs replace nursing staff as the majority component of the multidisciplinary team. The ‘partnership’ approach involves collaboration between the clinical service and an NGO partner. Staff provided by the NGO are non-clinical but have limited PSW roles. 24-hour clinical staff availability is generally not provided under the integrated staffing and is limited under the partnership approach. Novel staffing approaches were not meant to alter a CCU’s core function. However, it is possible that reducing clinical support might limit the capacity to care for people experiencing higher levels of symptoms and disability.

Recently, Karan et al. (2022) ² published an analysis of 2019 Queensland CCU benchmarking data, concluding that, despite similar consumer acuity, the staffing models had different treatment approaches. However, this study excluded consumers residing at a CCU <91 days. Therefore, we re-analysed the benchmarking data to explore the possibility of differences in consumer acuity based on the staffing model.

We identified significant differences between staffing models (see Supplementary Tables 3-4). These differences included symptomatic and disability measures (HoNOS and LSP-16), and the likelihood of inpatient referral. Post-hoc analyses found differences between the clinical and integrated staffing groups, with higher total HoNOS and LSP-16 scores and higher levels of inpatient referrals under the clinical than the integrated staffing model.

Our re-analysis suggests that clinical staffing model CCUs may work with consumers experiencing more severe impairment than those operating the integrated staffing model. Significant differences between the consumer profile under the partnership configuration and the other approaches were not identified. Possibly, reduced 24-hour clinical staff availability under the integrated model may limit rehabilitation access for people with the highest support needs. Alternatively, the integrated staffing model may limit these services from being used as a step-down from acute inpatient care. However, many other factors could account for the observed differences that cannot be considered based on the available data. These include systematic bias in ratings of the routine outcome measures between models (i.e., who is completing the HoNOS and LSP-16), different referral patterns, and differences in the broader mental health support system in which the CCUs operate. More research is urgently needed to ensure decisions about the staffing of CCUs are evidence-informed.

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Supplemental Material - Does fundamentally altering the staffing of clinical rehabilitation services impact their function?

Supplemental Material for Does fundamentally altering the staffing of clinical rehabilitation services impact their function? by Nikela Lalley, Donna Jones, Terry Stedman, and Stephen Parker in Australasian Psychiatry