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COMMUNITY TRANSLATION REPORTThe Link-Me TrialAugust 2021

Link-me was funded by the Australian Government Department of Health (2017-2020). Ethics approval for the study was granted by the University of Melbourne. The study was managed by researchers from the Integrated Mental Health Research Program, Department of General Practice,Melbourne Medical School, The University of Melbourne.STUDY INVESTIGATORS &RESEARCH TEAMProf Jane GunnDr Susan FletcherA/Prof Matthew SpittalProf Victoria  PalmerA/Prof Meredith HarrisProf Cathrine MihalopolousProf Philip BurgessDr Bridget BassiliosMs Maria PotiriadisDr Patty ChondrosDr Mary Lou ChattertonProf Jane Pirkis

Thank you to the Department of Health and the Brisbane North, North Coast, and North Western Melbourne PHNs for their assistance in developing and conducting the Link-me trial.

Link-me is a digitally supported, systematic, holistic, person-centred approach to triaging mental health problems in general practice. This mobile technology based, non-intrusive Decision Support Tool (DST) gathers information about a person’s biopsychosocial needs to triage them to low intensity (i.e., digital and self-help) or high intensity care (‘care navigation’: a form of care coordination). The DST was developed based on evidence collected over 15 years of our research with GPs and their patients.Australia has made large investments in primary mental health care reform. It is important that this investment reaches the right people, improves health outcomes and optimises patient experiences.Digitally supported models of care offer potential to organise mental health care at ‘scale’ and to better tailor support and management across the symptom severity spectrum. Stepped care approaches aim to deliver the least intensive intervention that is effective for an individual’s level of need. The evidence is promising but research and practice shows that it is difficult to implement.THE CHALLENGE1OUR SOLUTION

Triages primary care patients into mental health needs groups (low or high intensity care, depending on predicted symptom severity over time). Patients are matched to effective and evidence-based interventions;We evaluated Link-me using a gold-standard study design; called a randomised controlled trial (RCT)CLINICAL BENEFITSBuilt patient self-awareness and capacity to take ownership of care. Encouraged person-centered care and goal setting before consultation with their GP;Supported patients with severe symptoms who benefitted from the high intensity intervention: ‘care navigation’ and saw symptom improvements at 6 months;Supported modest improvements in people with mild depressive symptoms. Further testing and investigation into best practices for patient engagement in the Link-me model and stepped care interventions is required;Has economic and societal benefits. The Link-me model of stepped mental health care results in symptom improvements that in turn supports people towards recovery and enables social and economic participation.12345DOES IT WORK?23 general practices in three Primary Health Networks (PHNs) across three states.Patients screenedSETTING15,4742,098Patients completed DST40% low40% highNumbers triaged to high or low intensity• As a population-level system of care, Link-me was superior to usual care.• For those in high intensity care, greater engagement with care navigation resulted in additional clinical benefits. EXPERIENCES OF CARE• The Link-me model improved GP assessment and referral processes.• Patients said it increased their self-awareness and capacity to take ownership of their care.IN SUMMARYTHE DECISION SUPPORT TOOL:2

EXPERIENCES OF CARE NAVIGATIONI was seeing some doctors about pain stuff. I'm an ex-footballer and I'm 47 years old, but I've got a 100-year-old body from playing a lot of football and having accidents, and all types of things. So, I was seeing doctors about problems with limbs, depression and so forth. I imagine a lot of people go and see GPs to get pills for depression and pain and things like that… I think care navigation was created for people who are suffering from anxiety and depression, and who may not know that, and that they can actually get a different resource and potentially unclog some of the GPs. - Link-me participant“”EXPERIENTIAL MODEL OF CARE NAVIGATIONBased on what Link-me participants told us, the experiential model of care navigation was developed. The components of care navigation are detailed in terms of: setting priorities (the DST), developing a plan of action (DST information and care navigator contact), the support for referrals and links (care navigator working in conjunction with GP). The figure shows the interrelation between these parts and how participant experiences of dialogue and affirmation, insight and reflection, self-responsibility and self-confidence appear to drive the success of care navigation. General practitionerCare navigatorParticipant reported experiencesSelf-awareness grows from Decision Support Tool resultsIncreased knowledge of supports and services to meet goalsGreater feelings of connectionIncreased self-confidence to maintain actionsDialogue and affirmation Insight and reflection Self-responsibility Self-confidence“Opening up”“Reaching out”“Just reflecting”3

4This Australian-first individually randomised controlled trial, conducted across three states in Australia, provided gold-standard evidence to support the Link-me approach to system design. We found that Link-me was well-received by GPs, resulted in positive experiences of care to participants, and led to improved mental health outcomes at reasonable additional cost, particularly for those with severe and complex needs. Together, these findings indicate that Link-me can successfully organise mental health care at scale for the general practice population and tailor treatment to individual need across the symptom severity spectrum. Building on these findings, we suggest six actions that provide a ’roadmap’ to optimise Link-me in readiness for routine implementation into practice.NEXT STEPSIterative evaluation and learning cyclesIterative evaluation and learning cyclesDevelop digital platformAdapt for telehealth deliveryOptimise intervention componentsEnsure general practice engagementResources to support care navigationSpecial population and contexts• Refine and calibrate prognostic algorithm• Enhance interoperability with practice software• Increase capacity and ensure security• Embed tracking methods and step up/down criteriaSeamless pathways to Australian health and social care servicesAvailable and accessible stepped mental health care – Roadmap for Implementation of Link-me• Options for Decision Support Tool independent of GP setting• Care navigation contacts via video-conferencing• Encourage uptake of low intensity options• Optimise participation in care coordination• IT compatibility with Link-me digital platform• Training and support for practice staff• Define scope of care packages• Streamline care package service delivery and payments• Develop national care navigation workforce• Adapt Link-me for special populations• Explore suitability for integration into other service contexts

                                 For more information please contact:
 Primary Care Mental Health Research ProgramDepartment of General PracticeE: imh-gp@unimelb.edu.au | W: https://bit.ly/2Nj0T9GCOMMONWEALTH OF AUSTRALIACopyright Regulations 1969WarningThis material has been reproduced and communicated to you by or on behalf of theUniversity of Melbourne pursuant to Part VB of the Copyright Act 1968 (the Act).The material in this communication may be subject to copyright under the Act. Anyfurther copying or communication of this material by you may be the subject ofcopyright protection under the Act.Do not remove this noticeTranslational activities for Link-me are being supported by the ALIVE National Research Translation Centre to Implement Mental Health Care at Scale in Primary Care and CommunitySettings (APP2002047). The National Centre has been funded by a NHMRC Special Initiative inMental Health (2021-2026).E: info@alivenetwork.com.au