Mental health integrated care models in primary care and factors that contribute to their effective implementation: a scoping review.

BACKGROUND: In the state of Victoria, Australia, the 111-day lockdown due to the COVID-19 pandemic exacerbated the population's prevailing state of poor mental health. Of the 87% of Australians who visit their GP annually, 71% of health problems they discussed related to psychological issues. This review had two objectives: (1) To describe models of mental health integrated care within primary care settings that demonstrated improved mental health outcomes that were transferable to Australian settings, and (2) To outline the factors that contributed to the effective implementation of these models into routine practice. METHODS: A scoping review was undertaken to synthesise the evidence in order to inform practice, policymaking, and research. Data were obtained from PubMed, CINAHL and APA PsycINFO. RESULTS: Key elements of effective mental health integrated care models in primary care are: Co-location of mental health and substance abuse services in the primary care setting, presence of licensed mental health clinicians, a case management approach to patient care, ongoing depression monitoring for up to 24 months and other miscellaneous elements. Key factors that contributed to the effective implementation of mental health integrated care in routine practice are the willingness to accept and promote system change, integrated physical and mental clinical records, the presence of a care manager, adequate staff training, a healthy organisational culture, regular supervision and support, a standardised workflow plan and care pathways that included clear role boundaries and the use of outcome measures. The need to develop sustainable funding mechanisms has also been emphasized. CONCLUSION: Integrated mental health care models typically have a co-located mental health clinician who works closely with the GP and the rest of the primary care team. Implementing mental health integrated care models in Australia requires a 'whole of system' change. Lessons learned from the Mental Health Nurse Incentive Program could form the foundation on which this model is implemented in Australia.

Dermatological presentations to a regional Victorian hospital emergency department: A 1-year audit.

OBJECTIVES: The objective of this study is to describe the epidemiological features of each presentation with a primary dermatological diagnosis to a regional emergency department (ED). DESIGN: 1-year retrospective audit. SETTING: Regional Victorian hospital emergency department. PARTICIPANTS: Any presentation to this regional emergency department with a dermatological condition from 1 January 2020 to 31 December 2020. MAIN OUTCOME MEASURES: Dermatology presentations to the ED in 2020 and the prevalence of the associated primary diagnosis. RESULTS: In total, 4.7% (n = 1873) of ED presentations had a primary dermatological diagnosis. Of these, 1484 were ≥18 years of age and 389 were ≤17 years of age. Cellulitis (26.1%, n = 388) was the most common primary diagnosis among presentations ≥18 years. Non-specific rash was the most common diagnosis (23.6%, n = 92) in presentations ≤17 years. Indigenous Australians ≥18 years were more likely to be in a younger age group (p < 0.01), and dermatitis/eczema presentations ≥18 years (n = 10) were the largest diagnostic group referred to a dermatologist. A total of 134 (7.1%) patients ≥18 years travelled more than 50 km to the ED. There were no dermatological emergencies identified. CONCLUSIONS: A high proportion of presentations to this regional ED with a dermatological diagnosis could be well managed by a dermatologist or general practitioner (GP) as an outpatient. The findings of this study inform the need for future rural public dermatology services. Options include teledermatology, or a public weekly or fortnightly rapid review dermatology clinic with a visiting dermatologist, in the absence of a dermatologist onsite.

Effectiveness of personal recovery facilitators in adults with schizophrenia and other psychoses: A systematic review of reviews and narrative synthesis.

This review aimed to examine the evidence base for the use of personal recovery facilitators [non-psychopharmacological approaches] for adults with a diagnosis of schizophrenia and other psychoses. A systematic review (umbrella review) was conducted of reviews published in English between January 2010 and February 2022, which examined the effectiveness of personal recovery facilitators to support aspects of personal recovery as defined by the CHIME framework (connectedness, hope and optimism, identity, meaning and purpose, and empowerment). Twenty-one systematic reviews on thirteen different types of personal recovery facilitators [PRFs] were included in this umbrella review. Only one review sought to directly measure personal recovery processes according to the CHIME framework. Outcome measures mostly aligned with the processes of hope (21 reviews) and connectedness (19 reviews). Those related to empowerment (2 reviews), identity (5 reviews) and meaning and purpose (1 review) were less frequently the focus of PRFs. Yoga and music therapy showed the most promise as PRFs. Vocational treatments and integrated supported employment show good potential as personal recovery facilitators. However, together with narrative photovoice, art making and exhibition, they require further robust research to fully examine their impact. Personal recovery is only beginning to be considered as an intended outcome of interventions for persons with schizophrenia and other psychoses. This may be due in part to the continued predominance of the biomedical model approach to recovery within statutory services. Future evaluations of PRFs should include outcome measures that directly assess personal recovery according to the CHIME framework or other measures developed in consultation with recipients of these approaches. Review registration number and date: PROSPERO 2020 CRD42020215471: 10/11/20.

Strategies to Facilitate Mental Healthcare Access in Marginalised Local Communities: Case Studies from India and Australia.

BACKGROUND: Mental disorders are amongst the highest contributors to the Global Burden of Disease. However, despite the universal reach of these disorders, there are vast disparities in the provision of mental health services both between and within nations. Marginalised groups such as rural communities, ethnic minorities, refugees and indigenous peoples are known to be at higher risk of experiencing mental disorders but do not receive adequate care for it. AIMS OF THE STUDY: The purpose of this paper is to describe lessons learnt in designing and setting up mental health services for two marginalised communities - one in rural India and the other in an Aboriginal community in South Eastern Australia. METHODS: Two case studies of setting up a mental health service are described and compared to identify key elements to consider when developing services for hard to reach and marginalised communities. RESULTS: Four key elements were identified. They are: (i) Overcoming issues related to mental health literacy (Recognising mental illness and knowing where treatment is available) (ii) De-stigmatising the service (iii) Rendering the service culturally safe and (iv) Ensuring financial sustainability. DISCUSSION: Marginalised communities commonly experience an unmet need for mental health services. This includes indigenous peoples around the world who continue to experience various forms of disadvantage. As a result, traditional mainstream services are needing to rethink the way they do business so as not to exclude those who need them the most. The involvement of suitable link persons can play a crucial role in addressing the unmet need for mental health services in these communities. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The increasing movement of population groups across geographical boundaries including refugees has resulted in major changes in the cultural make- up of populations over a short period of time. The elements generated from these models can be utilised in expanding mental health service provision to include such communities. IMPLICATIONS FOR HEALTH POLICIES: Clear policies need to be developed to address the unmet need of hard to reach and marginalised communities for appropriate and accessible mental health services. This paper offers some direction for policy development in this space. IMPLICATIONS FOR FURTHER RESEARCH: Further research and trials of service models to address the unmet need for mental health services among marginalised communities can be informed by the lessons learnt from these experiences.

Factors affecting learning during internship: A qualitative study of junior doctors.

BACKGROUND AND OBJECTIVES: Internship is a crucial period of learning for medical graduates. The aim of this study was to ascertain what interns learned during internship, who they learned from and the type of environments that influenced their learning. METHOD: This qualitative study was conducted within the constructivist paradigm of Vygotsky's sociocultural theory of learning. RESULTS: Interns mostly learned what they were expected to learn. They built on their existing knowledge with help from a more knowledgeable other and in an environment that was conducive to learning except when they needed to manage complex situations on their own with no previous experience or training. Learning was influenced by factors related to the workplace, supervisor or senior doctor and learner. DISCUSSION: The learning environment is inextricably related to the professional behaviour of clinical teachers and supervisors. A safe and supportive learning environment is necessary for optimal learning outcomes during internship.

Care coordination as a collaborative element of recovery oriented services for persons with severe mental illness.

OBJECTIVE: To propose a model where care coordination can form part of recovery oriented care when it is included as a collaborative element of services for persons with severe mental illness. CONCLUSION: A recovery-oriented service requires more than clinical interventions. It also needs to address social determinants and be individualised or person centred. Multiple health and community services need to be involved. A care coordination model is capable of addressing multiple needs. It gives the client the first and foremost voice. It facilitates intersectoral collaboration, reduces the burden on clinical mental health services and is supported by mental health and community service personnel.

Hospital medication errors: a cross-sectional study.

BACKGROUND: Medication errors (MEs) are among the most common types of incidents reported in Australian and international hospitals. There is no uniform method of reporting and reducing these errors. This study aims to identify the incidence, time trends, types and factors associated with MEs in a large regional hospital in Australia. METHODS: A 5-year cross-sectional study. RESULTS: The incidence of MEs was 1.05 per 100 admitted patients. The highest frequency of errors was observed during the colder months of May-August. When distributed by day of the week, Mondays and Tuesdays had the highest frequency of errors. When distributed by hour of the day, time intervals from 7 am to 8 am and from 7 pm to 8 pm showed a sharp increase in the frequency of errors. One thousand and eighty-eight (57.8%) MEs belonged to incidence severity rating (ISR) level 4 and 787 (41.8%) belonged to ISR level 3. There were six incidents of ISR level 2 and only one incident of ISR level 1 reported during the five-year period 2014-2018. Administration-only errors were the most common accounting for 1070 (56.8%) followed by prescribing-only errors (433, 23%). High-risk medications were associated with half the number of errors, the most common of which were narcotics (17.9%) and antimicrobials (13.2%). CONCLUSIONS: MEs continue to be a problem faced by international hospitals. Inexperience of health professionals and nurse-patient ratios might be the fundamental challenges to overcome. Specific training of junior staff in prescribing and administering medication and nurse workload management could be possible solutions to reducing MEs in hospitals.

PERSPECTIVES: Recovery Oriented Services for Persons with Severe Mental Illness Can Focus on Meeting Needs Through Care Coordination.

BACKGROUND: The approach to care for persons with an acute illness is different from that for a person with a chronic disease. Whilst the goal of treatment for an acute illness is to cure the disease, a chronic condition has no cure as such, and hence management requires a team approach that is aimed at achieving goals that are jointly set by service users and providers. Severe and persistent mental illness (SPMI) is a chronic disease. However, in many mental health services, the approach to care for persons with SPMI is similar to those who have an acute mental illness. AIM: The aims of this paper are twofold: (i) to make an argument for recovery oriented services to focus on meeting clients' needs rather than on symptom reduction, (ii) to propose a model of service provision where clinical mental health services form a part rather than the mainstay of care for people with SPMI. RESULTS: Using examples from Australia's Partner's in Recovery initiative and other recovery literature, we start by describing how SPMI should be treated as a chronic disease that focuses on recovery. We then highlight how mental health services continue to monitor outcomes based on clinical rather than personal recovery. Next, we diagrammatically illustrate how needs can be aligned with the recovery process and illustrate how care coordination can be the hub of service delivery in a hub and spoke model. We conclude with comments on workforce requirements and costs of a needs-based recovery oriented service. DISCUSSION: In a needs based model, the role of the specialist mental health service will move from being at the centre of care to being one of the components of care and the role of the care coordinator will become central. Although, there are as yet no randomised controlled trials to show that meeting needs of persons with SPMI will significantly contribute to their recovery, preliminary studies show that it is possible. IMPLICATIONS FOR HEALTHCARE PROVISION AND USE: The role of the care coordinator becomes the hub of service provision collaborating with agencies such as family practices, specialist mental health services, legal, housing, employment, education, and community services. IMPLICATIONS FOR HEALTH POLICIES: A shift from the current model of care to a needs based approach requires a revolutionary change in the way we do business and will have to be the largest shake up of the mental health service system since deinstitutionalisation. IMPLICATIONS FOR FURTHER RESEARCH: It is a long journey from the status quo to a needs based approach. The first step would be to gather more evidence on the usefulness of addressing people's needs in achieving recovery.

Job satisfaction of rural medical interns: A qualitative study.

OBJECTIVE: To study reasons for job satisfaction and dissatisfaction among interns. DESIGN: Using a qualitative methodology, one-to-one interviews were conducted with interns. SETTING: The study was based at a Victorian Rural Intern Training program. PARTICIPANTS: Twelve interns from the program were interviewed during their final rotation. MAIN OUTCOME MEASURES: Reasons for job satisfaction and dissatisfaction among rural interns. RESULTS: Reasons for job satisfaction included feeling supported in the workplace as well as getting quality supervision, teaching and clinical exposure. Reasons for job dissatisfaction included poor access to administration, unduly stressful working situations, lack of support for mental health and well-being, and poorly organised teaching sessions. CONCLUSION: The internship experience, together with the people they are influenced by, can determine a doctor's future career pathway. It is therefore vital for internship coordinators and hospital managers to facilitate a positive internship experience. The findings have implications for human resource management policy and practice in rural hospitals.

Unmet needs of persons with a severe and persistent mental illness and their relationship to unmet accommodation needs.

This is a cross-sectional study of unmet needs of persons enrolled in Australia's Partners in Recovery (PIR) initiative. It aimed to explore the unmet needs reported by persons with a severe and persistent mental illness (SPMI) and to examine the associations between unmet accommodation needs and other unmet needs. The study was undertaken in the Gippsland region of Victoria from February to May 2015. Data were collected from the administrative database for the PIR initiative in Gippsland, which was held by the Gippsland Primary Health Network. Data on unmet needs, as measured by the Camberwell Assessment of Needs Short Appraisal Schedule, were analysed using proportions and logistic regression. Psychological distress, daytime activities, company/someone to spend time with and employment and volunteering were the most commonly reported unmet needs. Participants with unmet accommodation needs were less likely to receive information on their condition or access other services. They also had unmet needs relating to food, money, transport, childcare, looking after home, physical health, psychological distress and self-care. Supported accommodation may not be enough for persons with SPMI who have poor functioning skills and are incapable of looking after themselves. Services such as Housing First that have shown promising results need to be part of a comprehensive strategy to care for persons with severe and enduring mental illness.

Profile of transcultural patients in a regional Child and Adolescent Mental Health Service in Gippsland, Australia: The need for a multidimensional understanding of the complexities.

BACKGROUND: Several childhood stressors related to immigration have been documented, and it is important for clinicians to understand and address the various factors that may lead to or act as maintaining factors of mental disorders in children and adolescents. AIMS: To describe the cultural profile of transcultural patients presenting to a Child and Adolescent Mental Health Service (CAMHS) in regional Victoria and identify the most common disorders and psychosocial stressors they presented with. METHOD: Descriptive analysis was applied to 101 case records of patients with a transcultural background who attended the CAMHS of Latrobe Regional Hospital in Gippsland Victoria from 2013 to 2017. The Adverse Childhood Experience questionnaire was retrospectively applied to capture psychosocial stressors such as 'bullying', 'racism' and 'family conflict', sexual abuse, physical violence, parents with mental illness and parental substance use. RESULTS: Almost 60% of patients were male and over 46% Aboriginal. Those from a non-Aboriginal background belonged to 19 different cultural entities, the most common of which was a mixed Asian and European heritage. The most common diagnoses were disruptive mood dysregulation disorder (38.6%), attention-deficit hyperactivity disorder (32.7%) and developmental trauma disorder (26.7%). The most common psychosocial stressors were conflict and death in the family (44.6%), domestic violence (41.6%) and emotional abuse (34.7%). 'Parent in jail' and 'domestic violence' were associated with having an Aboriginal background ( p < .005). 'Cultural differences with parent' was associated with a non-Aboriginal background ( p < .005). CONCLUSION: This study provides a snapshot of challenges faced by children from different cultural backgrounds while adjusting in a rural area in Australia. A broad-based formulation and cultural awareness by clinicians can enable a better understanding of the complexities, guide management plans and inform public health policies for primary prevention and early intervention.

A Care Coordination Model Can Facilitate Interagency Collaboration When Designing Recovery-Oriented Services.

The purpose of the current article is to highlight the potential of a care coordination model in promoting interagency collaboration when designing recovery-oriented services. The authors argue the case using exemplars from the literature and lessons learned from Australia's Partners in Recovery initiative. Interagency collaboration is paramount when designing a recovery-oriented service system. A care coordination model has the potential to overcome most challenges that preclude implementation of service system integration. Although the care coordination model is relatively new in recovery-oriented services and effectiveness studies of this model have yet to be undertaken, the model has the potential to be a viable alternative to service system integration. [Journal of Psychosocial Nursing and Mental Health Services, 57(5), 38-43.].

Lower Income Levels in Australia Are Strongly Associated With Elevated Psychological Distress: Implications for Healthcare and Other Policy Areas.

Background: Australia is a high-income country with increasing income inequality. It is unclear whether Australia's well-developed mental healthcare system is making a difference to population mental health and the Federal Government has targeted outcomes accountability in service funding strategies. In high-income countries, evidence generally suggests that income inequalities increase mental disorders among the poor. This study examined psychological-distress rates-a marker of mental ill- health-as varying by income among Australians living within and outside of capital cities. Methods: Secondary data analysis was undertaken using the population-level mental health indicator of the Kessler Psychological Distress Scale (K10) as reported for 12,332 adults in the 2011/2012 National Health Survey (NHS) of Australia. K10 scores of 22 and higher indicated high/very-high distress, and 30 and higher denoted very-high distress. Very-high distress levels are strongly predictive of serious mental illness. Results: Among the poorest one-fifth of Australians, 1 in 4 people have psychological distress at a high/very-high level; this compares to about 1 in 20 people in the richest one-fifth of Australians. About 1-in-10 people making up the poorest one-fifth of Australians have current very-high distress, and this reduces to <1-in-50 people in the richest one-fifth. These disparities are consistent both within and outside of capital cities. The national prevalence of elevated distress within income quintiles varies greatly, with Poor/Rich Quintile Ratios of typically 4-5 for high/very-high levels and 7-8 for very-high levels. These effects operate more powerfully in areas marked by higher scores on the Index of Relative Socioeconomic Disadvantage. Conclusions: Altering the strong association of lower income levels in Australia with elevated psychological distress would require a multi-dimensional social policy and healthcare approach. To assess the effectiveness of adopted strategies, population level indicators need to be developed with regular data-collection. The Poor/Rich quintile ratio (P/R QR) for high/very high K10 scores is a potential candidate for a mental health inequality outcome indicator since it is easily calculated from data obtained from a regularly conducted national survey, is easily understood and resonates with a wider audience. Further research on the development of such indicators is also needed.

Referral patterns and implementation costs of the Partners in Recovery initiative in Gippsland: learnings for the National Disability Insurance Scheme.

OBJECTIVE:: The purpose of this paper is to provide some learnings for the NDIS from the referral pattern and cost of implementing the Partners in Recovery initiative of Gippsland. METHOD:: Information on referral areas made for each consumer was collated from support facilitators. Cost estimates were determined using budget estimates, administrative costs and a literature review and are reported from a government perspective. RESULTS:: Sixty-three per cent of all referrals were made to organisations that provided multiple types of services. Thirty-one per cent were to Mental Health Community Support Services. Eighteen per cent of referrals were made to clinical mental health services. The total cost of providing the service for a consumer per year (set-up and ongoing) was estimated to be AUD$15,755 and the ongoing cost per year was estimated to be AUD$13,434. The cost of doing nothing is likely to cost more in the longer term, with poor mental health outcomes such as hospital admission, unemployment benefits, prison, homelessness and psychiatric residential care. CONCLUSIONS:: Supporting recovery in persons with Severe and Persistent Mental Illness is likely to be economically more beneficial than not doing so. Recovery can be better supported when frequently utilised services are co-located. These might be some learnings for the NDIS.

Outcomes of a care coordinated service model for persons with severe and persistent mental illness: A qualitative study.

BACKGROUND: Owing to difficulties faced by individuals with severe and persistent mental illness (SPMI) in accessing multiple services, the Australian Government trialed a care coordinated service model called the Partners in Recovery (PIR) initiative. MATERIAL: A total of 45 stakeholders in Gippsland were asked what difference the initiative had made. DISCUSSION: The PIR initiative benefited not only clients and carers but also service providers. It addressed an unmet need in service delivery for individuals with SPMI. CONCLUSION: The PIR initiative has filled a gap in delivery of care for individuals with SPMI in Gippsland.

Roles and competencies of the Support Facilitator in Australia's recovery-oriented mental health initiative: a qualitative study from Gippsland, Victoria.

Objective This study explored the roles and competencies of Support Facilitators (SFs) engaged in the implementation of the Partners in Recovery initiative in a rural region of Victoria. Methods Semi-structured interviews were conducted with 32 stakeholders involved in the initiative, of which 15 were SFs. Results Two main themes and 10 subthemes emerged from the data: (1) SF competencies (which included an understanding of local services as well as administrative and social skills); and (2) the SF role (which included them being a single point of contact, providing care coordination, assisting the client to become self-reliant, achieving good outcomes for clients with confronting behaviours, judiciously using flexible funding, clearly outlining their role with clients and maintaining boundaries and performing a different role from that of the mental health case manager). Conclusions The roles and competencies of the SF in the Partners in Recovery initiative in Gippsland were congruent with the defined characteristics of a care coordination approach. The results highlight how the SF role differs from that of traditional clinical case managers. These findings are important for future mental health service policy development, education and training of mental health practitioners and recruitment of personnel to care coordination roles. What is known about the topic? There is a growing body of literature highlighting the importance of care coordination in delivery of positive outcomes for people with chronic and complex health problems. However, little is documented about the care coordination role of SFs as part of the Partners in Recovery initiative in Australia. What does this paper add? This paper identifies the roles and competencies of SFs in the Partners in Recovery initiative in a rural region of Victoria. The paper highlights that the emergent competencies and role functions are congruent with the defined characteristics of a care coordination approach but differ from that of mental health case managers. What are the implications for practitioners? These findings are important for future mental health service policy development, education and training of mental health practitioners and recruitment of personnel to care coordination roles.

Health workers' views of help seeking and suicide among Aboriginal people in rural Victoria.

OBJECTIVE: To explore Aboriginal health workers' views about help seeking and suicide. DESIGN: One-to-one semi-structured interviews were conducted with participants. Data were analysed thematically. SETTING: Njernda Aboriginal Corporation and the Yorta Yorta Aboriginal Community of Echuca, Victoria. PARTICIPANTS: Twenty seven participants (15 men and 12 women) over the age of 18 years were interviewed, of which 24 were Aboriginal workers employed by Njernda Aboriginal Corporation. RESULTS: Four themes emerged from the data: 'Difficulty in talking about one's problems'; 'Reasons for not talking with family and peers'; 'Lack of access to suitable formal supports' and 'Consequences of not talking about one's problems'. CONCLUSION: This study unpacks the problem of help seeking for psychological distress among rural Aboriginal people and highlights its association with suicide and self-harm. The findings suggest that the barriers faced by Aboriginal people in sharing their traumatic emotions exist from childhood to older age groups and this inability to seek and obtain help can lead to self-harm and suicide. Similar studies on Aboriginal help seeking and suicide will help shed more light on this challenging issue.

Mental health academics in rural and remote Australia.

CONTEXT: The significant impact of mental ill health in rural and remote Australia has been well documented. Included among innovative approaches undertaken to address this issue has been the Mental Health Academic (MHA) project, established in 2007. Funded by the Australian Government (Department of Health), this project was established as a component of the University Departments of Rural Health (UDRH) program. All 11 UDRHs appointed an MHA. Although widely geographically dispersed, the MHAs have collaborated in various ways. The MHA project encompasses a range of activities addressing four key performance indicators. These activities, undertaken in rural and remote Australia, aimed to increase access to mental health services, promote awareness of mental health issues, support students undertaking mental health training and improve health professionals' capacity to recognise and address mental health issues. MHAs were strategically placed within the UDRHs across the country, ensuring an established academic base for the MHAs' work was available immediately. Close association with each local rural community was recognised as important. For most MHAs this was facilitated by having an established clinical role in their local community and actively engaging with the community in which they worked. In common with other rural health initiatives, some difficulties were experienced in the recruitment of suitable MHAs, especially in more remote locations. The genesis of this article was a national meeting of the MHAs in 2014, to identify and map the different types of activities MHAs had undertaken in their regions. These activities were analysed and categorised by the MHAs. These categories have been used as a guiding framework for this article. ISSUES: The challenge to increase community access to mental health services was addressed by (i) initiatives to address specific access barriers, (ii) supporting recruitment and retention of rural mental health staff, (iii) developing the skills of the existing workforce and (iv) developing innovative approaches to student placements. Strategies to promote awareness of mental health issues included workshops in rural and remote communities, specific suicide prevention initiatives and targeted initiatives to support the mental health needs of Indigenous Australians. The need for collaboration between the widely dispersed MHAs was identified as important to bridge the rural divide, to promote project cohesiveness and ensure new ideas in an emerging setting are readily shared and to provide professional support for one another as mental health academics are often isolated from academic colleagues with similar mental health interests. LESSONS LEARNED: The MHA project suggests that an integrated approach can be taken to address the common difficulties of community awareness raising of mental health issues, increasing access to mental health services, workforce recruitment and retention (access), and skill development of existing health professionals (access and awareness). To address the specific needs and circumstances of their community, MHAs have customised their activities. As in other rural initiatives, one size was found not to fit all. The triad of flexibility, diversity and connectedness (both to local community and other MHAs) describes the response identified as appropriate by the MHAs. The breadth of the MHA role to provide university sponsored educational activities outside traditional student teaching meant that the broader health workforce benefited from access to mental health training that would not otherwise have occurred. Provision of these additional educational opportunities addressed not only the need for increased education regarding mental health but also reduced the barriers commonly faced by rural health professionals in accessing quality professional development.