Stepped care service delivery model

The Ministry of Health recommends the primary care sector adopt a stepped care approach to mental health service delivery.

Stepped care is a system of delivering and monitoring treatments so that the most effective, yet least resource intensive, treatment is delivered to service users first¹. A stepped care model is one in which:

• there are interventions of different levels of intensity available to the service user
• the service user's needs are matched with the level of intensity of the intervention
• there is careful monitoring of service user outcomes, allowing treatments to be ‘stepped up' if required
• service users usually move through less intensive interventions before receiving more intensive interventions (if necessary)
• there are clear referral pathways between the different levels of intervention
• the importance of supporting self care is recognised as an important aspect of managing demand².

There is now good evidence for both the clinical and cost effectiveness of stepped care models^{1 3}. Potential benefits of a stepped care approach include:

• increased recognition rates
• greater numbers of people receiving treatment for mental health and addiction problems
• increased recovery rates
• reduced disability and impairment related to work, family and social participation
• reduced socioeconomic and ethnic inequalities in mental health and addiction
• economic and social benefits associated with fewer patients developing more severe mental health and addiction problems
• a more cost-effective way of delivering services
• shorter waiting times
• reduced demand for specialist mental health and addiction services
• reduced stigma for patients
• a more relaxed environment for the patient
• increased patient satisfaction
• a more holistic and integrated approach to treating health problems
• greater opportunities for promotion, prevention, and early intervention in mental health and addiction
• increased chances of a person accepting a psychiatric assessment if it does not involve going to the hospital
• enhanced communication between GPs and specialists.

The image above provides a visual representation of a stepped care model. The target group for primary mental health care is the central area of the pyramid. A person's needs may be matched with services of different levels of intensity. For example, the needs of service users with mild mental and/or addiction disorders may adequately be addressed through extended GP consultations, active monitoring, lifestyle advice and/or green prescriptions, e-therapies, or through libraries to access self-help resources. Those with moderate mental and/or addiction disorders may require a more thorough assessment by a primary mental health coordinator, possibly followed by a brief (talking therapy) intervention, package of care (POC), and/or drug prescription.

Source

• Ministry of Health. 2009. Towards optimal primary mental health care in New Zealand: A discussion paper. Wellington: Ministry of Health.

References

1. Needham M. 2007. Treating common mental health problems through stepped care: Informing, commissioning, provider management and practice based commissioning in primary care. Cheshire, England: Care Services Improvement Partnership (CSIP), North West Development Centre.
2. Chapple A, Rogers A. 1999. Self-care and its relevance to developing demand management strategies: A review of qualitative research. Health and Social Care in the Community 7: 445-54.
3. Walters P, Tylee A. 2005. In: M Maj, J Lopez-Ibor, N Sartorius, M Sato, A Okasha (eds). Early detection and management of mental disorders. World Psychiatric Association. Chichester: John Wiley.