Table 4. Tradition 2: Interventions to improve care planning and coordination in the international literature.

Author/s	Interventions/changes to services	Outcome
Fossey et al 2012—Australia [55]	Introduction of the PNCQ (Perceived need for care questionnaire) tool: a self rated needs assessment tool	Qualitative analysis indicated perceived needs for care are multifaceted. For example, dissatisfaction with taking medication may coexist with perceiving medication needs as met. Communication was the main perceived barrier to meeting patients’ needs. The PNCQ was therefore helpful for screening patients’ needs.
Kuno et al 1996—USA [56]	Compared the effectiveness of traditional case management (CM) which included care coordination function, and Intensive Case Management (ICM) consisting of care coordination function and the provision of direct support to the client in the community by nurses.	Over the follow-up year, 65% of the ICM clients and 76% of the CM clients were rehospitalized. Among those rehospitalized, the time in the community prior to the rehospitalization was significantly longer for the ICM clients than for the CM clients. The ICM clients had significantly more contacts with case managers than the CM clients on average. The provision of non-treatment, direct support services may make a significant difference in reducing annual hospital care.
Nagel et al 2009—Australia [57]	Psycho-education resources and a brief intervention motivational care planning (MCP) were developed and tested in collaboration with aboriginal mental health workers in three remote communities.	Significant improvement in terms of well-being and outcomes which were sustained over time. There was also significant advantage for treatment for alcohol dependence with improvement also in cannabis dependence. Results suggest that MCP is an effective intervention for indigenous people with mental illness.
Horner & Asher 2005—Australia [58]	Shared care programme developed to move patients with chronic psychiatric disorders to the care and management of GPs. Intervention consisted of a dedicated mental health GP providing support to patients and doctors; multi-disciplinary care planning meetings including patient and carer and jointly developed individual management plan.	Outcomes suggest that patients’ mental health is not compromised and may be enhanced by transfer to GPs within a shared care model. Indicators of mental health outcomes showed mostly improved patient symptomatology and functioning. Communication procedures between all parties were improved. Such a shared care protocol may fulfil the requirements of the recovery-based model of mental health.
Bauer et al 2006—USA [59]	A collaborative model for chronic care to improve bipolar disorder. The intervention introduces an outpatient specialty team consisting of a nurse care coordinator and a psychiatrist. The nurse care coordinator aims to enhance access to care and continuity of care.	Significant reduction in affective episodes, primarily mania. Broad-based improvements were demonstrated in social role function, mental quality of life, and treatment satisfaction. Reductions in mean manic and depressive symptoms were not significant. The intervention was cost-neutral while achieving a net reduction of 6.2 weeks in affective episode. Functional and quality-of-life benefits also were demonstrated, with most benefits accruing in years 2 and 3.
Lawn et al 2007—Australia [60]	GPs and mental health case managers introduced a patient centred care model to assist patients with serious mental illness to identify their self-management needs and negotiate care plans with clinicians. Peer support workers provided one-to-one education and motivational support to patients.	The intervention significantly improved self-management and quality of life at 3 to 6 months follow-up. Significant improvements were seen in shared decision-making and collaboration with case managers and GP as well as in symptom monitoring and management. Qualitative feedback was highly supportive of this approach with patients and service providers reporting considerable gains. No patients required hospitalisation during the study period, and patients had fewer admissions in the 12 months post participation compared to the 12 months prior to participation in the study.
Lakeman 2008—Australia [61]	Introduction of practice standards into adult mental health services and carer participation in mental health services.	Increases in documented carer participation, particularly in relation to treatment or care planning. The majority of carers and service users were satisfied with their level of participation. The introduction of practice standards was an acceptable, inexpensive way of introducing modest improvements to the quality of family and carer participation.
Druss et al 2011—USA [62]	Coaching, motivational interviewing techniques and development of action plans in community mental health settings.	Sustained improvements were observed in the intervention group in quality of primary care preventive services, quality of cardiometabolic care, and mental health-related quality of life. From a health system perspective, by year 2, the mean per-patient total costs for the intervention group were $932 less than for the usual care group, with a high probability that the program was associated with lower costs than usual care.
Marchinko & Clarke 2011—Canada [63]	Introduction of a client-held record/booklet (the “Wellness Planner”) consisting of e.g. a crisis plan, contact names and telephone numbers and self management strategies as well as personal daily planner and monthly development and personal goals planner.	Statistically significant increases were seen in empowerment, continuity of care, and satisfaction with services after 3 months of using the Wellness Planner. Qualitative data further demonstrated positive acceptance of the booklet by the users. Findings of the study suggest that the use of such a booklet could have a positive impact on the recovery of individuals.
Woltmann et al 2011—USA [64]	Electronic decision support system (EDSS) to create a shared-decision-making plan.	Compared with case managers in the control group, the intervention group were significantly more satisfied with the care planning process. Compared with consumers in the control group, those in the intervention group had significantly greater recall of their care plans and care decisions three days after the planning session. The study demonstrated that clients can build their own care plans and negotiate and revise them with their case managers using an EDSS. The EDSS brought to light preferences held by clients that were not previously known by case managers.
Quantitative	Secondary analysis of patient data (Kuno et al 1999); Review of patient outcomes & GP satisfaction survey (Horner & Asher, 2005); RCT (Bauer et al 2006; Druss et al, 2011; Woltmann et al 2011); Survey (Lakeman, 2008)
Qualitative	Semi-structured interviews (Fossey et al 2012)
Qualitative and quantitative mixed methods	Surveys and focus groups (Lawn et al, 2007); RCT and participatory action research (Nagel et al, 2009); Survey and free-text (Marchinko & Clarke, 2011)