Evaluation of Marathon Health’s Partners in Recovery Care Coordination Model (Specialist Support Coordination Team Program): Summary of Findings

The Specialist Service Coordination Team (SSCOT) program is the result of an innovation grant from NSW Health. Running in conjunction with Marathon Health’s Partners in Recovery (PIR) program, it provides a detailed assessment and care coordination service to people living with severe mental illness whose recovery journey has stalled or who show signs of cognitive impairment. The SSCOT team’s ‘step-in, stepout’ work provides a wellness and recovery action plan based on a comprehensive suite of specialist assessments. This plan is developed in partnership with local service providers who then implement the plan. The SSCOT program is as exemplar of contemporary mental health policy in action. The evaluation revealed very high consumer, carer and partner satisfaction with the service. This included the respectful nature of the service and the focus on life goals, including carers as partners in the recovery journey, and the competence of SSCOT staff.The service also showed high levels of program fidelity across the clinical assessment and care planning process, though not all benchmarks achieved the 85% target. Increased emphasis on communication with GPs and focus on physical health assessment present opportunities for service improvement. The program would also benefit from increased attention to completing its standardised assessments, and recording client-related and service development activity data. This data would have greatly assisted the evaluation team to assess service effectiveness and service efficiency.The staffing deployment appears efficient and effective in meeting its objectives.The multidisciplinary team of psychologists, occupational therapist, social worker and speech therapist work part-time in SSCOT and also work for other services. This helps program sustainability and facilitates connection to other services. The model prioritises engagement with partner providers and the development of a shared recovery plan. The specialist assessment, collaborative planning and wellness focus are essential elements of this model.Several praiseworthy aspects of this program warrant mention: A structured and planned approach to local collaboration and partnership High levels of service recipient satisfaction The use of a comprehensive suite of specialist mental health assessments Working in partnership with carers A strengths-based, life goals approach to wellness and recovery planning.The fundamental challenge associated with this initiative does not lie with the SSCOT program itself. It lies with the ability of service partners to reliably implement the wellness and recovery action plan.The evaluation concluded that the SSCOT program provides a sustainable and valuable contribution to mental health. It enables local services to provide more effective and efficient care to people living with severe mental illness. This is a valuable contribution to mental health care and recovery in the region. The model appears transferrable to other regions and would