Talking Mental Health in home care services for older people: implementation and process evaluation

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However, these needs are not adequately addressed across the aged care system due to factors such as stigma, capacity, and access barriers. This study co-designed, implemented, and evaluated a pilot program, ‘Talking Mental Health’, to promote the uptake of mental health evidence into routine community aged care services in Australia. Methods We co-designed the Talking Mental Health program’s formal organisational protocols as a key implementation strategy and used a rapid-cycle implementation, assessment, and adaptation methodology based on the RE-AIM framework. A mixed methods process evaluation used the Consolidated Framework for Implementation Research (CFIR) to identify facilitators and barriers to the implementation process. Data were collected from organisational systems on the use of the protocols, and from surveys and focus groups with staff, people with lived experience, and experts. Descriptive statistics assessed the degree of adoption and effectiveness of the protocols, and qualitative methods identified characteristics influencing the uptake of the program. Results The analysis and evaluation identified that the implementation of Talking Mental Health was effective, with modified protocols adopted well by staff to identify older people with mental health needs and improve care and access to support. The evaluation identified key contextual and implementation factors that affect the successful adoption of strategies to enhance the uptake of evidence in community aged care. Conclusions The findings indicate that successful uptake of the Talking Mental Health program in community aged care requires 1) the alignment of external and organisational strategies with staff concerns for clients, 2) leaders to demonstrate commitment to addressing client and staff needs and 3) the process to involve stakeholders, with clear communication and easy-to-use strategies for implementation. Future research should examine how to scale this approach to other aged care settings and sustain the use of the Talking Mental Health and other mental health protocols to improve access to mental health interventions for older people. Rapid-cycle implementation process evaluation co-design mental health protocols stakeholders aged-care Figures Figure 1 Figure 2 Contributions to the literature Implementation strategies to improve the health and well-being of older people in community aged care do not receive sufficient research attention Organisational culture, leadership, and stakeholder engagement are important for implementation effectiveness This study demonstrates how successful implementation processes in the aged care sector need to be fit for purpose, recognising constraints, and embedding protocols into existing organisational systems The findings address the recognised gaps in the literature for greater rigour, engagement with theory, and stakeholder engagement in implementing needed improvements in the growing community aged care sector. Background Globally, it is estimated that 14% of adults aged over 60 years live with mental disorders such as anxiety and depression, with 27% of deaths from suicide occurring in older people (1). In Australia, similar numbers (17% of people aged over 55 years) experience depression and anxiety, with higher rates among those living in residential aged care (2). There is evidence that early intervention addressing older adults’ mental health needs can improve health outcomes, quality of life (3), and reduce the risk of critical events including unplanned hospitalisations, preventable mortality, and premature entry to residential aged care (4). However, older adults are less likely to self-report their mental health concerns than younger people (3) or often delay seeking help due to factors such as stigma, capacity, and access (5). In Australia, where this study was conducted, the recent Australian Royal Commission into Aged Care Quality and Safety (6) noted that: “the needs of older people with mental health conditions are not being adequately addressed across the aged care system” (p. 69). Systemically, there are major barriers to accessing mental health services for older adults worldwide. Barriers include a lack of integrated psychiatric community care, cost (7), other complex health needs being prioritised, and perceptions that mental health care is not needed (8). In Australia, mental health services are not generally eligible for funding support from aged care home support (9). Instead, older people living in the community are currently required to seek mental health support via their general medical practitioner and private mental health services, which are facing a critical national shortage and high gap fees (10, 11). Despite the challenges to providing optimal support for the mental health needs of older people, there is a growing recognition among policymakers, service providers, and members of the community that innovation is required in this area (12). For example, in the UK, a blueprint for mental health support proposes up-skilling staff and volunteers (13). In the USA, access to behavioural health practitioners has been expanded with the integration of mental health with ageing services (14). In Australia, enhancing responsiveness to the mental health needs of older people receiving aged care is a priority of the strengthened Australian Quality Standards (15), and the National Mental Health Workforce strategy commits to growing a skilled workforce to meet rising demands (16). Support from a trusted care provider may be a critical resource for promoting access to mental health services for older adults (17). Community aged care workers, often called home care workers (HCWs), provide essential non-clinical support services such as personal care, meal preparation, medication assistance, and home maintenance to individuals in their own homes. They have regular contact with older people living in their own homes and can build ongoing and trusted relationships. For some older people, their HCWs may be the only people they have regular contact with. Thus, HCWs are a potential key resource for supporting the mental health needs of older people. To fulfill this potential, HCWs need adequate levels of training (particularly in mental health literacy) and clear organisational systems to respond to mental health and well-being concerns (including reporting, follow-up, and referral). However, the Australian Royal Commission into Aged Care Quality and Safety (6) noted that many staff who work in aged care are “not sufficiently skilled or trained to identify and support people living with mental health conditions.” (p.69). Additionally, meeting aged care recipients’ mental health needs presents unique challenges in the community care context, where HCWs commonly provide in-home services to a diverse range of clients with varying needs and expectations, and across different locations, often working within tight time constraints (4, 18). A fit-for-purpose implementation strategy is required to address these challenges (19, 20). The present implementation study describes the co-design, implementation, and evaluation of the "Talking Mental Health” (TMH) project to improve response to mental health needs in community aged care. TMH consists of a new suite of four care protocols and mental health training within an Australian aged care provider, designed to enable aged care workers (focusing on HCWs) to promote access to mental health support for clients living in the community more effectively and confidently. TMH aims to (1) improve the identification of mental health needs, and (2) improve access to support services for older recipients of aged care services living in the community with mental health needs. Methods Design: This implementation study included the co-design of TMH, which resulted in formal organisational protocols to suit the community aged care context (21) and used a rapid-cycle implementation, assessment, and adaptation methodology based on the RE-AIM framework (22) to track any modifications and assess the reach, effectiveness, adoption, implementation, and maintenance of the TMH program. A mixed methods process evaluation (23) using the Consolidated Framework for Implementation Research (CFIR) (24) identified facilitators and barriers to the implementation process. Study setting: This study was conducted in collaboration with Uniting AgeWell - a Victorian and Tasmanian community aged care provider in Australia - as part of their Mental Health and Wellbeing Framework and Suicide Prevention Action Plan (25). This policy framework was informed by a review of contemporary literature and qualitative interview data obtained from Uniting AgeWell stakeholders, including staff and older clients. Uniting AgeWell selected one region of home care services in North-West metropolitan Melbourne to pilot the TMH project based on having a mixed client and staff demographic and the capacity to undertake an implementation project. The chosen region services approximately 2000 customers and employs approximately 200 staff. Study Procedures: A summary of the key project activities is in Figure 1. The co-design of the TMH program, including of its implementation strategies to fit with the community aged care context (21) was followed by a rapid-cycle implementation approach that allowed for mid-course assessments and adaptations (22) to the systems and protocols developed and implemented in four distinct phases over 12 months: (a) Governance and Protocol co-design phase, (b) Staff training phase, (c) Protocol pilot and testing phase, and (d) Protocol refinement. A process evaluation assessed how well the implementation process met the aims and identified barriers and enablers to the adoption and maintenance of the new protocols. Co-design phase, governance, and process: A Project Advisory Group (PAG) was formed, comprising the research team, two senior staff of the implementation organisation Uniting AgeWell, three consumer representatives, and two representatives from mental health support and training organisations. The PAG met regularly to provide advice to the research team on mental health, intervention strategies, preventing crises, and encouraging positive aspects of well-being. They engaged as co-designers, drafted and reviewed protocols, and made recommendations on the implementation and maintenance of the project. Members external to the research team and aged care provider were offered payment for their time according to hourly rates for clinical experts and research advisory groups. A co-design process with PAG members, Uniting AgeWell staff (HCWs, care coordinators, care managers, and executive staff), and older care recipients (with and without self-identified mental health concerns) was facilitated by the research team. See Table 3 for participant details. The co-design process included participation in two co-design workshops, four weeks apart, which were structured on previous co-design work of the team (26) and using World Café methodology (27). Data from the first co-design workshop was used by the research team and PAG to inform and refine the TMH program, including creating new and modifying existing Uniting AgeWell organisational protocols. The second workshop provided additional information on protocol refinement before field testing the implementation of the new processes and protocols (e.g. via questions on feasibility, roll-out, and engagement). The co-design process resulted in the development of an implementation strategy for four new care protocols (21). Table 1 summarises the changes for staff in implementing the new protocols: Intake, Conversations, Reporting, Elevation. Table 1. The Talking Mental Health program: Changes for staff to implement the revised protocols Changes for staff Aim of protocol Actions required Changes for clinical staff and office staff Protocol A Intake: to better capture information about mental health at intake Use the Quality of life tool (QOL-ACC) to assess client needs Add information to HCW task list relevant to well-being Protocol B Conversations : to promote conversations about mental health and well-being Complete e-learning about mental health and communicating with older people about mental health Protocol C Reporting : Follow up of reports by office staff to respond to observations of frontline HCW staff Send text message to HCW to acknowledge receipt of report Requirement to review care plan and assess the need for a check-in and urgency Protocol D Elevation : to ensure appropriate referral, follow-up and escalation where required Complete training in Mental health first aid for older people Complete Client check-in to identify if urgent need or risk identified Elevate report to Registered Nurse or Manager for action to refer client to health care professional Send text message to HCW and update HCW task list Changes for HCWs Protocol B Conversations : to provide HCWs with skills to engage and recognise mental health needs Complete e-training on the basics of mental health Complete e-training on communicating with older people about mental health Complete in person training on the use of the new processes and protocols Protocol C Reporting : to better report observations of front-line HCW staff Check task list for mental health needs After each client visit, report observations by an organisation phone app on client well-being ‘good’, ‘fine’, ‘not good’ Add free text message on conversations, concerns, changes Protocol D Elevation : to improve follow up for Receive feedback on actions taken Review task list for added tasks and observations Staff education/training phase: Staff training was developed by Uniting AgeWell with guidance from the research team and PAG for the HCWs and office-based staff (including care organisers, care advisors, and clinical staff) . Two online modules about mental health and the mental health needs of older people were created by the research team and made available to all staff in the pilot location . These tookhalf an hour each to complete and were based on publicly available resources provided by research collaborators, Beyond Blue, an Australian mental health organisation, who were represented on the PAG. Training was also provided to office-based staff in Mental Health First Aid, provided by research collaborators Mental Health First Aid International, an Australian mental health organisation, who were also represented on the PAG. In-person sessions assisted staff in using the new processes. HCWs learned how to use the new smartphone-based reporting and response system introduced to their daily work, and office-based staff were trained in the changes to the intake and assessment system and HCW task lists, and how to undertake check-ins with clients for whom a report had been received. Comprehensive staff manuals were developed for the new processes . TMH Protocol testing phase: All staff in the selected home care region of the aged care provider used the new protocols in their daily work over ten weeks (Figure 2). During this phase data were collected on numbers and types of intakes and assessments, field reports, check-ins, escalations, and referrals. This documented the extent to which the TMH new protocols were identifying mental health needs and improving access to interventions. Surveys of staff during this test phase sought feedback on how the TMH program was working, where further refinements or training were needed, and any alterations to the protocols that would make TMH easier to use. Protocol refinement phase The PAG met mid-way through the testing phase to review data and staff feedback on simplification of the tool and made refinements. This reduced questions and options in the HCW report to simplify the automatically generated supervisor reviews when there were concerns identified. The revised version included only one question: ‘How did your client seem today?’ with reduced options of “Good/Fine” and “Not good/unmet needs” but retained the ability to provide free text if required. At the end of the testing phase, the PAG reviewed all data again and suggested recommendations for further rollout of the TMH program in Uniting AgeWell Home Care services. Data Collection Participants The number of individual Uniting AgeWell staff, consumer representatives, clients, and external experts who participated in co-design and implementation activities was collected from anonymous attendance records, survey responses, and feedback forms. Surveys Approval to seek survey and focus group responses from staff in the test region was granted by the Flinders University Human Research Ethics Committee. Information was provided to all staff in the test region about the research, inviting participation in surveys and focus groups in hard copy and by text message to remote staff. An online survey link was sent by text message by Uniting AgeWell to staff. The survey reiterated information on the voluntary and non-identifiable nature of the survey, and the withdrawal process by closing the web browser or not submitting the survey response. By submitting the survey response, participants gave implied consent. The same process was used for the anonymous pre- and post-implementation surveys of staff knowledge, skills, and confidence. The surveys were developed for this study using Qualtrics software (28) adapted from the Mental Health Literacy (MHL) (29, 30) measures, consisting of brief items (e.g., “Mental health is a normal part of ageing”, or “ It’s best not to talk about issues related to mental health, as they might get upset”) that tested knowledge and beliefs aligned with staff roles in home care ( Supplementary File 1). Staff were reminded once to complete the survey via text message or email within two weeks. Anonymous staff feedback surveys at the mid-point and end point of the test phase were also distributed online via Qualtrics software, with similar time frames and reminders (Supplementary File 1 ). File audit A file audit was conducted by UA, extracting non-client data from a data warehouse to maintain confidentiality according to privacy and data security requirements. A Structured Query Language (SQL) Script was applied to the data in the clinical management system, with search terms related to possible mental health issues (which were identified by the PAG, see Supplementary File 2). This data was collected at two time points –during the 10 weeks immediately preceding the pilot (baseline), and during the 10-week test phase. Focus Groups Two focus groups were conducted after the testing phase, one with HCWs and one with office-based staff. The questions were adapted from Participants were invited in-person and by text messages from Uniting AgeWell to join a focus group interview, with those volunteering to participate having the process of consent, recording, withdrawal, and de-identification of transcripts explained and the opportunity to sign a consent form at the start of the interview. De-identified transcripts of the discussions were uploaded to NVivo 14 (31) and coded independently by two researchers (RH and LdlP) using the CFIR framework (32). Any disagreements were resolved by discussion and involvement of a third person (TW). (Supplementary File 3.) Co-design workshops and other data Written notes and summaries from the workshops, extracts of written comments and synthesis from feedback surveys, emails, meetings with staff, and minutes of meetings of the research group and PAG were de-identified and uploaded to NVivo 14 (31) and coded in the same way using the CFIR framework (32). Analysis and Evaluation A concurrent mixed-methods design (33) collected qualitative and quantitative data pre-, during, and after the implementation of TMH. The Standards for Reporting Implementation Studies (StaRI checklist) (34) was used to assess the quality of this study (see Supplementary File 3). A deductive framework analysis identified qualitative data from focus groups and comments in surveys, feedback, field notes, and meeting records using the online guide to coding and analysis of the key constructs of CFIR (35). An inductive analysis identified barriers and facilitators. The components of relevance to this study were 1) the characteristics of the individuals involved in the implementation, 2) the aspects of the inner setting and outer setting of the implementation study, 3) the characteristics of the intervention, and 4) the process of implementation. Process evaluation Primary measures for the process evaluation were the adoption of the protocols by staff and the effectiveness of training and systems changes on staff mental health literacy. Secondary measures of reach, implementation, and maintenance of the protocols for the questions used in focus groups for staff, and in the analysis of transcripts, documents, and text comments in survey responses, meeting and field notes were guided by the CFIR framework (24, 32) . Quantitative and qualitative data were collected to examine the contextual factors affecting the outcomes. The measures, data sources and the associated methods of analysis corresponding with each dimension in the RE-AIM framework are outlined in Table 2. Table 2. Dimensions of the RE-AIM framework and measures identified to evaluate the Talking Mental Health Project Aim: to improve identification of mental health needs and improve access to support services for older recipients of aged care services living in the community with mental health needs. Dimensions of RE-AIM Measures Source Analysis Primary outcomes Adoption Uptake of new processes: Quantitative: De-identified file audit pre and post-implementation Numbers of clients where screening and identification processes applied. Numbers of elevation processes used Uniting AgeWell reports of use of protocols from the client management system and digital file audit word search from a data warehouse Comparison of numbers of reports, assessments, and use of escalation process pre and post-testing phase Descriptive statistics of the proportion of clients identified and responses by staff Effectiveness Mental health literacy and confidence of staff: Quantitative and qualitative: Staff survey of change in mental health knowledge, skills, and confidence and written comments Pre- and post-pilot surveys of knowledge skills and confidence of staff (Qualtrics) Descriptive statistics: compare changes in knowledge, skills, and confidence in talking about mental health. Qualitative analysis of comments Secondary outcomes Reach Engagement and retention of participants: Quantitative: numbers and types of staff and clients involved in each aspect of the project Attendance records, surveys, and field notes on participation for co-design, pilot, surveys, and training for staff, clients, and experts Retention over the time of the project and reasons for variations or engagement levels Implementation Barriers and facilitators, degree of acceptability, feasibility of the project: Qualitative: identification of factors influencing implementation for participants Quantitative: feedback surveys from staff Focus group transcripts and free text comments were provided via surveys, notes, emails, and meeting records to identify feedback from staff and advisory group on implementation. Mid-point and end of pilot surveys Qualitative analysis based on CFIR framework of contextual and implementation characteristics and inductive analysis of other themes in the data. Barriers and facilitators identified. Descriptive statistics. Maintenance Improvements and expected ongoing use: Qualitative: suggested improvements and future intentions, sustainment over time Focus groups, field notes, text comments in surveys to identify improvements and intentions to maintain implementation. File Audit of use of protocols Qualitative analysis on suggested improvements intentions identified and observations by the implementation team on feedback and review mechanisms. Sustained use of protocols Results Participants The characteristics of the 157 individual participants during each phase of the TMH study are in Table 3 . Table 3 Participants in TMH study Number of individuals Type of participation Pre-implementation During implementation Post Implementation * 7 Individual non-staff participating across a range of TMH activities Non-staff n = 5 In Project advisory group and co-design workshops External clinical experts 2 2 2 Consumer representatives 3 3 0 Clients n = 2 Co-design workshops 2 n/a n/a *150 Individual Staff participating across a range of TMH activities Staff n = 2 Project Advisory Group 2 2 2 Staff n = 19 Co-design workshop 1&2 19 n/a n/a Staff n = 59 Baseline Survey of Mental Health Literacy 59 n/a n/a Staff n = 25 Post-pilot survey Mental Health Literacy n/a n/a 25 Staff n = 25 Feedback surveys Mid-point End pilot n/a 20 25 Staff n = 20 * 2 incl in other activities Focus groups n/a n/a 22 *Staff included in other activities Training Online and In-person sessions 113 Office staff: MHFA 23 OPMHFA 24 Refresher 15 n/a *Total Participants in implementation activities N = 157 Note. * Participants who were involved in several activities were only counted once overall. HCW = Home Care Workers. MHFA = Mental Health First Aid Training. OPMFA = Older Person’s Mental Health First Aid Training. Refresher = Refresher training. Results in relation to the RE-AIM Dimensions: In the context of the number of total clients in the relevant catchment area remaining similar across the baseline (pre-pilot) and pilot phases (only a 1.96% increase in clients from baseline to pilot), results in relation to the RE-AIM dimensions: Adoption Key indicators obtained from the client management systems data (Table 4 ) confirmed that the TMH protocols were well adopted by staff. Most notably, there was almost a fourfold increase in the number of client quality-of-life assessments administered via the Quality of life- Aged Care Consumers (QOL-ACC) instrument (which measures both health-related and psychosocial aspects of quality of life) from baseline (8.7% of total care plan assessments) to the pilot phase (35.8% of care plan assessments). The QOL-ACC was used 294.67% more often in the pilot period (296 times) as compared to the baseline period (75 times), demonstrating excellent adoption. The new reporting system implemented by HCWs at the end of their shifts during the 10-week testing phase resulted in 24,181 reports being generated. Of these reports, there were 275 instances across 149 clients (5% of total clients) where HCWs reported “Not Good/Unmet Needs”. This routine use of regular reports provided office-based staff with alerts (607 supervisor reviews) where a wide range of health concerns were noted. They reviewed care plans and case notes, then decided if they needed to elevate the response to check in with the client, assess needs, and refer for interventions where needed, indicating excellent adoption and consistent reporting. Table 4 Data extracted from client management system reports for the selected pilot region Data extracted Baseline Testing phase Comment Number of clients 2955 3013 Increase 1.96% Number of QOL-ACC assessments completed 75 296 Increase 294.67% Number of Care plan assessments completed 859 827 Decrease 3.73% Number of welfare check-ins conducted 909 1057 Increase 16.28% Number of client reports completed n/a 24,181 Excellent uptake of reporting protocol Number of supervisor reviews generated due to mental health and well-being concerns n/a 607 Reporting of additional information resulted in further clinical review Number of additional information (Dated notes) provided to office staff with further information n/a 523 Of these 523 notes, 319 notes (60%) included the mental health-related key search words, indicating that 60% of the reported concerns were related to mental health and well-being. Number of clients with at least 1 supervisor review generated due to mental health and well-being concerns? n/a 324 11% of all clients had a review generated in the pilot period due mental health and well-being concerns Number of times “Not Good/Unmet Needs” was reported relating to mental health and well-being concerns n/a 275 9% of the total number of clients in the pilot period File Audit results revealed no increase in usual care plan reviews and related assessments between the baseline (n = 859) and the testing phase n = 827). This was due to fewer clients being due for annual care plan reviews during the pilot period. Due to this timing relating to annual reviews, Table 5 shows a decrease in the number of intake assessments and care plans during the testing phase (n = 309) compared to baseline (n = 486). However, the overall number of assessments increased in the testing phase due to introducing the reporting protocol for HCWs (total baseline assessments = 486; total testing phase assessments = 584). The overall ratio of mental health-related terms identified per assessment remained relatively stable at around 1.3 at the baseline and testing phase for office-based staff assessments. The ratio of mental health terms/reports for HCW reports during the testing phase was 1.08, indicating that HCWs were regularly referring to mental health-related issues in the text accompanying “Not good/Unmet Needs” reports (Table 5 Here). Table 5 Results of file audit for mental health terms at baseline and during the pilot period Text search for mental health terms Baseline Testing phase Office-based staff assessments 486 309 Word Count 626 405 Ratio 1.3 1.3 HCW assessments 0 275 Word Count 0 298 Ratio 1.08 Total Assessments 486 584 Word Count 626 703 Effectiveness Data from 59 completed baseline staff surveys indicated that 50% of staff had adequate knowledge of the mental health needs of older people, and 81% were confident of what to do when they were concerned about a client’s mental health and well-being. Due to the anonymity of the surveys and the lack of matching between pre- and post-test responses, direct comparisons could not be made. However, post-test phase survey data (n = 25 completed surveys) and qualitative feedback from the training sessions (n = 24) indicated that staff generally perceived their participation in TMH as having increased their mental health knowledge and confidence. For example, responses to the post testing phase survey indicate increased skills in talking about mental health (88% agreed), improved knowledge about the mental health needs of older people (69% agreed), and more than two-thirds of participants reported increased confidence in talking with clients about mental health (72% agreed). Staff provided feedback that the training was enjoyable and added confidence to talk about mental health, thereby adding value to their roles. Implementation of the full TMH process from report to referral (see Fig. 2 ) resulted in the initiation of 19 client check-ins by office staff during the testing phase, with all alerts raised followed up after the formal data collection period. This reflects a time lag in the completion of check-ins by office staff due to the initial high number of unnecessary supervisor alerts, but provides an indicator of the sustainment of the modified protocol use. Reach Table 3 shows the activities of a total of 157 participants in the development and implementation of the TMH project. Additionally, all staff (n = 188) of the pilot region used TMH in their regular work processes, with 150 individuals participating in at least one implementation activity (co-design workshops, surveys, training, feedback, and focus groups). Those involved in co-design and survey feedback reported appreciation for being included and valued the opportunity to voice their opinions. The staff training was enjoyed by almost all (96%) as being relevant, the right amount of time (100%), and well delivered (98%). Members of the PAG (5 non-staff, 2 staff, 6 researchers), together with 34 staff and two clients of Uniting Age Well, were involved in co-designing the protocols for implementation and contributed expertise, advice, and ongoing commitment to the project implementation. The PAG members reported that their involvement was purposeful and inclusive and addressed an issue of concern to them, which achieved positive results. The clients were pleased to share their perspectives, and that the provider was addressing an important area of need for older people. Implementation and Maintenance: According to participants, despite some initial technical difficulties with the reporting and review protocols, the implementation process was well organised and met all milestones in the project plan within a tight timeframe. The rapid-cycle implementation approach enabled the project team to respond quickly to feedback and make changes to the protocols and system settings. PAG oversight provided advice on mental health training and assessments and refinements to the protocols, while the co-design process engaged a range of perspectives to identify acceptable processes, and the involvement of all staff in a home care region tested the feasibility of the protocols in the real world. Quotes from staff about their experience of the implementation process are presented in Table 6 . The key concerns and areas for improvement identified by staff included 1) the desire for greater input into project planning, 2) concerns around increased workload arising from reviewing HCW reports, 3) a lack of a clear communication method from office staff to HCWs following a report to “close the loop” and 4) challenges in communication and system implementation given the remote nature of HCW work, and few opportunities for direct contact with peers and supervisors. The TMH project achieved significant uptake of the protocols and offered effective training to staff on older people’s mental health. The embedding of protocols into existing systems was acceptable to most staff, and all staff of the test site used TMH as part of their daily work. Clients with mental health concerns were appropriately identified and followed up, resulting in added support and monitoring. The number of referrals for interventions was not collected. Table 6 Summary of qualitative data collected from focus groups, survey comments, and notes of meetings, using the constructs of CFIR for analysis. Constructs of CFIR Quotes from staff Overall summary of data Outer context: policy, social needs “If we don't focus on mental health at all, we will be out of touch with the world and people” HCW1 “It's about meeting needs. It's about valuing and respecting the individual” OS1 Staff understood the purpose of focusing on the mental health needs of older people and the required national quality standards reporting. Inner setting: culture, structure, and communication “There's not enough of that direct support for the carers” OS2 “Carers are feeling a distance from management” HCW2 The structure of home care services (HCWs and office-based staff, and managers) was seen as a barrier to communication and support generally. Individual characteristics: knowledge, stage of change, self-efficacy “Now we have a focus, we have a vision, that we just go there knowing what mental health is. And now we sort of understand it” HCW3 The training and simple reporting systems helped HCWs understand client needs and clarified their roles. This facilitated feedback about clients to office-based staff. Intervention Characteristics: adaptability, complexity, design “It's not complicated to use but it is very time-consuming” OS2 Office-based staff experienced an increase in workloads, with reports to be reviewed and the need for flexibility in assessments. Process of implementation: engagement, roll out, and planning “It was a brand-new idea so there's going to be teething problems. It’s to be expected”. OS 4 “We don't know if anyone even reads them (the reports)” HCW1 While some staff saw the project as “really productive” increasing communication between staff, others reported not being involved enough in the planning and rollout and not getting feedback on the reports. Process of implementation: Reflecting and evaluation “(It) would be good for this project to go on, to move forward” HCW4 While the project was seen as “proactive” and “innovative”, staff offered suggestions for improvement: further simplification, consistency in feedback to HCWs, flexibility with assessment processes, and broadening the use of the reporting to include all concerns identified by HCWs. Note: OS = Office Staff; HCW = Home Care Worker Results are summarised against the primary and secondary measures using the RE-AIM framework in Table 7 . Table 7 Summary of results of Talking Mental Health project against RE-AIM primary and secondary measures Results for Primary measures of RE-AIM framework Adoption : There was significant uptake and use of protocols by staff during the pilot period Effectiveness : Increased mental health literacy (MHL) and confidence of staff in talking about mental health Increased identification of mental health concerns and support for clients to access interventions Results for Secondary measures of RE-AIM framework Reach : 157 people (both staff and non-staff stakeholders) participated in the development and implementation of TMH project Implementation process : Met all milestones. A collaborative effort drove implementation, and feedback from staff identified improvements needed Facilitators for staff : - TMH has simple tools that fit in with work processes, and good training is provided - Involvement in co-design and implementation was appreciated - TMH improved feedback about clients to office staff by HCWs - TMH is an innovative approach to meet needs. Barriers for staff : - Insufficient involvement in adapting their processes to the TMH steps - Streamlining of intake system is needed to reduce paperwork - Insufficient communication about the process led to a lack of clarity for some staff - More support for HCWs was desired to cope with their mental health and the demands of the job. Maintenance : Ongoing use of the protocols with suggested improvements and ongoing training needed Discussion The implementation of TMH at the pilot site improved staff commitment to mental health and well-being and their skills in mental health, increased the uptake of evidence to better identify older clients within the community who have mental health concerns, and improved access to support for their well-being. The TMH project resulted in the successful co-design and 100% uptake and adoption of four key protocols by aged care staff at Uniting AgeWell. Due to the implementation of TMH, there was a fourfold increase in quality of life assessments (as they were integrated into the Uniting AgeWell processes), improved awareness, recognition and reporting of client mental health and well-being needs, including 9% of the total number of clients in the testing phase identified as having mental health and well-being concerns that were likely to not have been identified otherwise. Implementation efforts in health and aged care show the impact that complexity and contextual constraints have on outcomes. A recent review ( 36 ) found that while there were an increasing number of studies on the implementation of innovations in aged care, few focused on community aged care, few used implementation theory or frameworks, and only 15% involved consumers in the process. The key factors that were found to influence change included organisational culture and resources, capabilities of staff, and stakeholder engagement in implementation strategies. The current study of the TMH project was designed with these factors in mind and successfully implemented the new TMH protocols, thus addressing recognised gaps in the literature for greater rigour, engagement with theory, and stakeholder engagement in implementing needed improvements in the growing community aged care sector. In TMH, a key focus was on facilitating an equal co-design process, where the expertise and perspectives of diverse participants were valued at all stages of the project, from design and refinement to evaluation of outcomes and improvements. Participants were paid for their participation either in hourly pay rates for staff, by invoice, or by gift cards based on hourly rates for clients and members of PAG. The use of co-design and World Café ( 26 , 37 ) methods provided an opportunity to build on other ideas equally and to review the agreed key ideas. The collaborative co-design and partnership model between researchers, aged care managers and staff, external clinical experts, consumer representatives, and clients enabled planning and a responsive approach to implementation, modifications, and consideration of a range of perspectives. Evaluation results showed the co-design approach was well accepted and appreciated by participants, and the implementation of the TMH project resulted in a high take-up of the protocols by staff, better identification of clients with mental health concerns, and increased discussion of service options with clients. Indeed, because the TMH project was informed by and led by a cooperative implementation team, the new protocols were able to be embedded within an existing client reporting and management system. This led to the intervention being compatible with most existing processes and easy to use for most staff. The staff training (both online and in person) was well attended by staff, was well received and effective, and enabled HCWs to effectively identify clients who were experiencing mental health or well-being concerns. Office-based staff (e.g., care advisors and care coordinators) gained mental health literacy and confidence through education and training and used the new elevation process to review reports and decide on the appropriate response. Despite considerable ongoing constraints on the aged care workforce and resources, the rapid assessment, evaluation, and implementation approach ( 38 ) in this study demonstrated the effective use of responsive planning, co-design, testing, and feedback approaches to engage and upskill staff and to design, implement, and embed new processes within existing systems. The introduction of the TMH program into daily community aged care work routines created initial technical and workload difficulties for staff, which required quick turnaround of changes to system issues and feedback to staff. This also identified the need for updated and streamlined processes. The rapid cycle implementation design was effective in making changes as needed to the protocols and system settings and provided opportunities for staff to give feedback and see changes made. The combination of mixed methods with a “rapid, iterative teams-based approach” recommended by McNall and colleagues ( 39 ) p.166, offered increased rigour to the evaluation. The feedback loops built into the implementation phases kept staff engaged and the implementation team focused on the adoption of the protocols. The model used to evaluate the implementation was similar to Morgan and colleagues ( 40 ), who used the CFIR to identify barriers and facilitators to implementing dementia care in primary health care in Canada. Like their study, the characteristics of the intervention, the local setting, and the process of implementation were found to be influential in the implementation of TMH. The constrained funding structure of home care and a mobile community-based workforce was identified as a barrier to communication and engagement of staff, yet the commitment of staff and the organisation to older people’s well-being was a strong driver of positive outcomes. A significant facilitator shared by staff and managers was the recognition of the need for a focus on mental health in community aged care. This recognition was aligned with both a response to older people’s needs and changes in the quality standards regulating home care services. Barriers in the local setting identified by staff included cross-staff role communication opportunities and funding constraints. For example, while HCWs have monthly in-person meetings, it was found that office-based staff rarely attended these. Further, as HCWs are a mobile community-based direct care workforce with heavy workloads, their ability to participate in the co-design workshops and provide feedback via surveys was limited. Limitations and suggestions for further research Future research is needed on the maintenance and scalability of this approach to suit diverse older populations in different locations. The TMH project was implemented in one region (in a metropolitan area) only, and transferability to other locations and contexts cannot be assumed. The needs of older people and aged care staff in other areas may be different according to the local availability of services, cultural and linguistic background, and socio-economic status of clients and staff. Community aged care is one piece of the local context, and connections with other services are vital for coordinated responses. An appraisal of the context and readiness for implementation of the protocols would be needed if expanding the program for further roll-out ( 41 ). HCWs also indicated a desire for further focus on and greater support for their own mental health and well-being from managers, which should be a focus of future workforce research. Despite the involvement of staff in the development of a mental health framework before the TMH project and ongoing communication about the co-design process and implementation of protocols, some staff perceived that communication about the changes was not sufficient. A process to gauge the reach and receptiveness to various communication strategies may be needed to improve the implementation process ( 42 ). A pre- and post-implementation survey of knowledge, skills, and confidence of staff was planned to test the significance of changes in mental health literacy during the testing phase. This was not possible as different staff responded to each survey, and their responses could not be compared. This limited the measure of effectiveness. However, other measures, such as the significant uptake of the protocols and the appropriate identification of clients with mental health concerns, demonstrated that the training and use of protocols were effective. Improved communication about the need to complete both surveys may have improved the use of this measure. There were several limitations in the client management system, which reduced design options and adaptability for the reporting. The existing complicated assessment process for office-based staff increased documentation, and the overlap of items in various processes used outside of the TMH protocols was seen by staff as a barrier to implementation. We were unable to identify the number of referrals suggested to clients or provided formally, because of client privacy, as well as how referrals are captured in the clinical management system. As a result, a specific recommendation to provide a separate data field for referrals relating to mental health and well-being was made because of this TMH project. Finally, identifying the outcome of referrals was not possible due to privacy conditions, and was not the focus of the implementation outcomes. Conclusions This study is one of the few examples of successful implementation of programs that exist in the aged care sector, which includes the elements of co-design with all affected parties, involvement of older people, and a concurrent process evaluation of a real-time innovation in community aged care services. The commitment of the organisation (Uniting AgeWell)) and collaborative involvement of the project team and staff were essential to drive the system changes and integration into the existing work processes. The rapid implementation of the four phases of the project, from governance and co-design to staff training, protocol testing, and refinement, was achieved through the significant investment from the provider. The methodology meaningfully involved older people and experts in the development process, and by embedding the protocols within daily work processes and simplifying processes as the protocols were tested, the project was able to reach all staff of the implementation site. Effective training increased the mental health literacy of staff and their capability to undertake their roles within the TMH protocols. The study also identified key areas for improvement that will inform the expansion of the TMH program across Uniting AgeWell services and in broader settings. This is a key opportunity to increase mental health awareness and integrate processes to improve the mental health and well-being of older people in the community. Abbreviations RE-AIM: Reach, Effectiveness, Adoption, Implementation, and Maintenance CFIR: Consolidated framework for implementation research UK: United Kingdom of Great Britain USA: United States of America HCW: Home Care Worker TMH: Talking Mental Health UA: Uniting AgeWell PAG: Project Advisory Group MHL: Mental Health Literacy SQL: Structured Query Language MMAT: Mixed Methods Appraisal Tool MHFA: Mental Health First Aid OPMHFA: Older Persons Mental Health First Aid QOL-ACC: Quality of life-Aged Care Consumer OS: Office Staff Declarations Ethical approval for this study was granted by the Human Research Ethics Committee of Flinders University, Australia (#6135) which is governed bythe Australian National Statement on Ethical Conduct in Human Research 2025, drawn from the principles of the Helsinki Declaration. Information sheets, consent forms and contact information for the researchers and the Ethics committee was provided to all staff to assist them in understanding the purpose and nature of the research, the consent and withdrawal process and how their anonymous or de-identified data would be used. Members of the research team met with staff in person, provided hard copies of information and consent forms, provided telephone and email contacts for further discussion and reiterated processes for voluntary consent and withdrawal from the research. Consent for Publication of images: Not applicable Availability of Data: All data generated or analysed during this study are included in this published article [and its supplementary information files]. Consent for the use of individual data did not allow for the public availability of transcripts due to privacy requirements. Competing Interests: The authors declare that they have no competing interests Funding: This research was funded by ARIIA (Aged Care Research & Industry Innovation Australia) (R3GA00080) with co-contributions by Uniting AgeWell to support the aged care workforce’s capability and knowledge. Authors Contributions: LdlP: Member of research team and PAG, coordinated the project and stakeholder engagement, reviewed the literature, sought ethics approval, revised the study protocol, developed training content, devised data collection and qualitative analysis, collected, analysed, and interpreted data, drafted and revised and submitted the manuscript NB: Member of research team and PAG, coordinated the provider involvement, developed and monitored project tracking and data capture, developed staff training, led staff communication and engagement, extracted and analysed systems data and staff feedback, modified processes, developed project reports, and reviewed and revised the manuscript and gave final approval RH: Member of research team and PAG, collected qualitative data, supported co-design processes, analysed data from transcripts, reviewed findings, and the manuscript MC: Member of the research team, conceptualised the project, reviewed the literature, sought partners and funding, developed the study protocol, contributed intellectual content, revised the draft manuscript, and gave final approval TW: Member of the research team and Chair of PAG, conceptualised the project, sought partners and funding, contributed intellectual content, managed the funding and reporting for the project, supervised the project coordinator, contributed the quantitative analysis, reviewed the draft and revisions of the manuscript, and gave final approval AG: Member of the research team and PAG, contributed to the grant application and conceptualisation of the project, conceptualised and led the co-design process, sought stakeholder engagement and partners, contributed intellectual content, synthesized the co-design feedback, supervised the manuscript development, revisions, and gave final approval. Acknowledgements: We wish to acknowledge the generous contribution of the consumer representatives, the clients, mental health experts, co-designers, and the staff of Uniting AgeWell in this implementation pilot. Their involvement and the commitment of Uniting AgeWell to improving the mental health of older people in the community made this study possible We gratefully acknowledge the essential contributions of the PAG: Claire Kelly from MHFA, Chris Dutton from Beyond Blue, Helen Mathews and Sherry-Ann Bailey from Uniting AgeWell, and community advisors Sue Aberdeen, Don and Robin Fergusson. References World Health Organisation. Mental Health of Older Adults Fact sheet Geneva: World Health Organisation; 2023 [updated 20/10/23. Available from: https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults. Australian Institute of Health and Welfare. Mental health in aged care Canberra: Australian Government; 2024 [updated 19/07/2024. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6730629","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":479694090,"identity":"52c571f7-31cf-4fd0-b3bf-643d71f8a206","order_by":0,"name":"Lenore de la Perrelle","email":"","orcid":"","institution":"Flinders University","correspondingAuthor":false,"prefix":"","firstName":"Lenore","middleName":"de la","lastName":"Perrelle","suffix":""},{"id":479694091,"identity":"24ed6031-9db0-4120-b236-13760012057b","order_by":1,"name":"Nina Bowes","email":"","orcid":"","institution":"Uniting AgeWell","correspondingAuthor":false,"prefix":"","firstName":"Nina","middleName":"","lastName":"Bowes","suffix":""},{"id":479694095,"identity":"b9d806b4-f21a-415b-9802-ad4b7b10a015","order_by":2,"name":"Robin Harper","email":"","orcid":"","institution":"National Ageing Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Robin","middleName":"","lastName":"Harper","suffix":""},{"id":479694096,"identity":"4b934683-30d6-46bf-aab4-8fdc32f999d1","order_by":3,"name":"Monica Cations","email":"","orcid":"","institution":"Flinders University","correspondingAuthor":false,"prefix":"","firstName":"Monica","middleName":"","lastName":"Cations","suffix":""},{"id":479694097,"identity":"a8bfbb17-f966-4243-a429-5e31fb2bcce5","order_by":4,"name":"Tim D. 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Procura is the software platform used for the online client management system. HCW = Home Care Worker.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6730629/v1/87d659857ae8907e406695ac.png"},{"id":86019058,"identity":"6dfc472f-1ad4-43bb-ab00-89edeb46f018","added_by":"auto","created_at":"2025-07-04 11:28:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1738970,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6730629/v1/4406e37c-03ad-459c-9614-90dd338ccd6a.pdf"},{"id":86018369,"identity":"6cefeb38-9336-47c7-8250-ca1a9f80734f","added_by":"auto","created_at":"2025-07-04 11:20:38","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":26070,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1..docx","url":"https://assets-eu.researchsquare.com/files/rs-6730629/v1/837fab3d510164b8a864ffd5.docx"},{"id":86019056,"identity":"21338b70-7274-4360-a07e-c6d08cd74fec","added_by":"auto","created_at":"2025-07-04 11:28:38","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15452,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile2..docx","url":"https://assets-eu.researchsquare.com/files/rs-6730629/v1/9f7942bf53fd5717d3219774.docx"},{"id":86018151,"identity":"7733a112-25fc-4427-b2a8-0a431b36735c","added_by":"auto","created_at":"2025-07-04 11:12:38","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20517,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile3..docx","url":"https://assets-eu.researchsquare.com/files/rs-6730629/v1/37b5dcff4761d305c378e8fa.docx"},{"id":86018149,"identity":"d5d80c1e-91fd-49ba-b1f7-6842fb652596","added_by":"auto","created_at":"2025-07-04 11:12:38","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":17502,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile4.docx","url":"https://assets-eu.researchsquare.com/files/rs-6730629/v1/4f81a536135ee9aafd2e27b6.docx"},{"id":86018154,"identity":"0c52d5ec-4bff-40da-9eb6-ffd60968e973","added_by":"auto","created_at":"2025-07-04 11:12:38","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":49706,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile5..docx","url":"https://assets-eu.researchsquare.com/files/rs-6730629/v1/782999117048dde0c7177890.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Talking Mental Health in home care services for older people: implementation and process evaluation","fulltext":[{"header":"Contributions to the literature","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003eImplementation strategies to improve the health and well-being of older people in community aged care do not receive sufficient research attention\u003c/li\u003e\n \u003cli\u003eOrganisational culture, leadership, and stakeholder engagement are important for implementation effectiveness\u003c/li\u003e\n \u003cli\u003eThis study demonstrates how\u0026nbsp;successful implementation processes in the aged care sector need to be fit for purpose, recognising constraints, and embedding protocols into existing organisational systems \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThe findings address the recognised gaps in the literature for greater rigour, engagement with theory, and stakeholder engagement in implementing needed improvements in the growing community aged care sector.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eGlobally, it is estimated that 14% of adults aged over 60 years live with mental disorders such as anxiety and depression, with 27% of deaths from suicide occurring in older people (1). In Australia, similar numbers (17% of people aged over 55 years) experience depression and anxiety, with higher rates among those living in residential aged care (2). There is evidence that early intervention addressing older adults\u0026rsquo; mental health needs can improve health outcomes, quality of life (3), and reduce the risk of critical events including unplanned hospitalisations, preventable mortality, and premature entry to residential aged care (4). However, older adults are less likely to self-report their mental health concerns than younger people (3) or often delay seeking help due to factors such as stigma, capacity, and access (5). \u003c/p\u003e\n\u003cp\u003eIn Australia, where this study was conducted, the recent Australian Royal Commission into Aged Care Quality and Safety (6) noted that: \u0026ldquo;the needs of older people with mental health conditions are not being adequately addressed across the aged care system\u0026rdquo; (p. 69). Systemically, there are major barriers to accessing mental health services for older adults worldwide. Barriers include a lack of integrated psychiatric community care, cost (7), other complex health needs being prioritised, and perceptions that mental health care is not needed (8). In Australia, mental health services are not generally eligible for funding support from aged care home support (9). Instead, older people living in the community are currently required to seek mental health support via their general medical practitioner and private mental health services, which are facing a critical national shortage and high gap fees (10, 11). \u003c/p\u003e\n\u003cp\u003eDespite the challenges to providing optimal support for the mental health needs of older people, there is a growing recognition among policymakers, service providers, and members of the community that innovation is required in this area (12). For example, in the UK, a blueprint for mental health support proposes up-skilling staff and volunteers (13). In the USA, access to behavioural health practitioners has been expanded with the integration of mental health with ageing services (14). In Australia, enhancing responsiveness to the mental health needs of older people receiving aged care is a priority of the strengthened Australian Quality Standards (15), and the National Mental Health Workforce strategy commits to growing a skilled workforce to meet rising demands (16).\u003c/p\u003e\n\u003cp\u003eSupport from a trusted care provider may be a critical resource for promoting access to mental health services for older adults (17). Community aged care workers, often called home care workers (HCWs), provide essential non-clinical support services such as personal care, meal preparation, medication assistance, and home maintenance to individuals in their own homes. They have regular contact with older people living in their own homes and can build ongoing and trusted relationships. For some older people, their HCWs may be the only people they have regular contact with. Thus, HCWs are a potential key resource for supporting the mental health needs of older people. To fulfill this potential, HCWs need adequate levels of training (particularly in mental health literacy) and clear organisational systems to respond to mental health and well-being concerns (including reporting, follow-up, and referral). However, the Australian Royal Commission into Aged Care Quality and Safety (6) noted that many staff who work in aged care are \u0026ldquo;not sufficiently skilled or trained to identify and support people living with mental health conditions.\u0026rdquo; (p.69). Additionally, meeting aged care recipients\u0026rsquo; mental health needs presents unique challenges in the community care context, where HCWs commonly provide in-home services to a diverse range of clients with varying needs and expectations, and across different locations, often working within tight time constraints (4, 18). A fit-for-purpose implementation strategy is required to address these challenges (19, 20). \u003c/p\u003e\n\u003cp\u003eThe present implementation study describes the co-design, implementation, and evaluation of the \u0026quot;Talking Mental Health\u0026rdquo; (TMH) project to improve response to mental health needs in community aged care. TMH consists of a new suite of four care protocols and mental health training within an Australian aged care provider, designed to enable aged care workers (focusing on HCWs) to promote access to mental health support for clients living in the community more effectively and confidently. TMH aims to (1) improve the identification of mental health needs, and (2) improve access to support services for older recipients of aged care services living in the community with mental health needs. \u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003e\u003cstrong\u003eDesign:\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis implementation study included the co-design of TMH, which resulted in formal organisational protocols to suit the community aged care context (21) and used a rapid-cycle implementation, assessment, and adaptation methodology based on the RE-AIM framework (22) to track any modifications and assess the reach, effectiveness, adoption, implementation, and maintenance of the TMH program. A mixed methods process evaluation (23) using the Consolidated Framework for Implementation Research (CFIR) (24) identified facilitators and barriers to the implementation process.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStudy setting:\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in collaboration with Uniting AgeWell - a Victorian and Tasmanian community aged care provider in Australia - as part of their Mental Health and Wellbeing Framework and Suicide Prevention Action Plan (25). This policy framework was informed by a review of contemporary literature and qualitative interview data obtained from Uniting AgeWell stakeholders, including staff and older clients. Uniting AgeWell selected one region of home care services in North-West metropolitan Melbourne to pilot the TMH project based on having a mixed client and staff demographic and the capacity to undertake an implementation project. The chosen region services approximately 2000 customers and employs approximately 200 staff.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eStudy Procedures:\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eA summary of the key project activities is in Figure 1. The co-design of the TMH program, including of its implementation strategies to fit with the community aged care context (21) was followed by a rapid-cycle implementation approach that allowed for mid-course assessments and adaptations (22) to the systems and protocols developed and implemented in four distinct phases over 12 months: (a) Governance and Protocol co-design phase, (b) Staff training phase, (c) Protocol pilot and testing phase, and (d) Protocol refinement. A process evaluation assessed how well the implementation process met the aims and identified barriers and enablers to the adoption and maintenance of the new protocols.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCo-design phase, governance, and process:\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eA Project Advisory Group (PAG) was formed, comprising the research team, two senior staff of the implementation organisation Uniting AgeWell, three consumer representatives, and two representatives from mental health support and training organisations. The PAG met regularly to provide advice to the research team on mental health, intervention strategies, preventing crises, and encouraging positive aspects of well-being. They engaged as co-designers, drafted and reviewed protocols, and made recommendations on the implementation and maintenance of the project. Members external to the research team and aged care provider were offered payment for their time according to hourly rates for clinical experts and research advisory groups.\u003c/p\u003e\n\u003cp\u003eA co-design process with PAG members, Uniting AgeWell staff (HCWs, care coordinators, care managers, and executive staff), and older care recipients (with and without self-identified mental health concerns) was facilitated by the research team. See Table 3 for participant details. The co-design process included participation in two co-design workshops, four weeks apart, which were structured on previous co-design work of the team (26) and using World Caf\u0026eacute; methodology (27). Data from the first co-design workshop was used by the research team and PAG to inform and refine the TMH program, including creating new and modifying existing Uniting AgeWell organisational protocols. The second workshop provided additional information on protocol refinement before field testing the implementation of the new processes and protocols (e.g. via questions on feasibility, roll-out, and engagement). The co-design process resulted in the development of an implementation strategy for four new care protocols (21). Table 1 summarises the changes for staff in implementing the new protocols: Intake, Conversations, Reporting, Elevation.\u003c/p\u003e\n\u003cp\u003eTable 1. The Talking Mental Health program: Changes for staff to implement the revised protocols\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChanges for staff\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAim of protocol\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eActions required\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChanges for clinical staff and office staff\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eProtocol A \u003cstrong\u003eIntake: to\u003c/strong\u003e better capture information about mental health at intake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eUse the Quality of life tool (QOL-ACC) to assess client needs\u003c/li\u003e\n \u003cli\u003eAdd information to HCW task list relevant to well-being\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eProtocol B \u003cstrong\u003eConversations\u003c/strong\u003e: to promote conversations about mental health and well-being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eComplete e-learning about mental health and communicating with older people about mental health\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eProtocol C \u003cstrong\u003eReporting\u003c/strong\u003e: Follow up of reports by office staff to respond to observations of frontline HCW staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eSend text message to HCW to acknowledge receipt of report\u003c/li\u003e\n \u003cli\u003eRequirement to review care plan and assess the need for a check-in and urgency\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eProtocol D \u003cstrong\u003eElevation\u003c/strong\u003e: to ensure appropriate referral, follow-up and escalation where required\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eComplete training in Mental health first aid for older people\u003c/li\u003e\n \u003cli\u003eComplete Client check-in to identify if urgent need or risk identified\u003c/li\u003e\n \u003cli\u003eElevate report to Registered Nurse or Manager for action to refer client to health care professional\u003c/li\u003e\n \u003cli\u003eSend text message to HCW and update HCW task list\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChanges for HCWs\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eProtocol B \u003cstrong\u003eConversations\u003c/strong\u003e: to provide HCWs with skills to engage and recognise mental health needs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eComplete e-training on the basics of mental health\u003c/li\u003e\n \u003cli\u003eComplete e-training on communicating with older people about mental health\u003c/li\u003e\n \u003cli\u003eComplete in person training on the use of the new processes and protocols\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eProtocol C \u003cstrong\u003eReporting\u003c/strong\u003e: to better report observations of front-line HCW staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCheck task list for mental health needs\u003c/li\u003e\n \u003cli\u003eAfter each client visit, report observations by an organisation phone app on client well-being \u0026lsquo;good\u0026rsquo;, \u0026lsquo;fine\u0026rsquo;, \u0026lsquo;not good\u0026rsquo;\u003c/li\u003e\n \u003cli\u003eAdd free text message on conversations, concerns, changes\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eProtocol D \u003cstrong\u003eElevation\u003c/strong\u003e: to improve follow up for\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eReceive feedback on actions taken\u003c/li\u003e\n \u003cli\u003eReview task list for added tasks and observations\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003e\u003cstrong\u003eStaff education/training phase:\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eStaff training was developed by Uniting AgeWell with guidance from the research team and PAG for the HCWs and office-based staff (including care organisers, care advisors, and clinical staff)\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e Two online modules about mental health and the mental health needs of older people were created by the research team and made available to all staff in the pilot location\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eThese tookhalf an hour each to complete and were based on publicly available resources provided by research collaborators, Beyond Blue, an Australian mental health organisation, who were represented on the PAG. Training was also provided to office-based staff in Mental Health First Aid, provided by research collaborators Mental Health First Aid International, an Australian mental health organisation, who were also represented on the PAG.\u003c/p\u003e\n\u003cp\u003eIn-person sessions assisted staff in using the new processes. HCWs learned how to use the new smartphone-based reporting and response system introduced to their daily work, and office-based staff were trained in the changes to the intake and assessment system and HCW task lists, and how to undertake check-ins with clients for whom a report had been received. Comprehensive staff manuals were developed for the new processes\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003e\u0026nbsp;TMH Protocol testing phase:\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eAll staff in the selected home care region of the aged care provider used the new protocols in their daily work over ten weeks (Figure 2).\u003c/p\u003e\n\u003cp\u003eDuring this phase data were collected on numbers and types of intakes and assessments, field reports, check-ins, escalations, and referrals. This documented the extent to which the TMH new protocols were identifying mental health needs and improving access to interventions. Surveys of staff during this test phase sought feedback on how the TMH program was working, where further refinements or training were needed, and any alterations to the protocols that would make TMH easier to use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProtocol refinement phase\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe PAG met mid-way through the testing phase to review data and staff feedback on simplification of the tool and made refinements. This reduced questions and options in the HCW report to simplify the automatically generated supervisor reviews when there were concerns identified. The revised version included only one question: \u0026lsquo;How did your client seem today?\u0026rsquo; with reduced options of \u0026ldquo;Good/Fine\u0026rdquo; and \u0026ldquo;Not good/unmet needs\u0026rdquo; but retained the ability to provide free text if required. At the end of the testing phase, the PAG reviewed all data again and suggested recommendations for further rollout of the TMH program in Uniting AgeWell Home Care services.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eData Collection\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003ch4\u003eParticipants\u003c/h4\u003e\n\u003cp\u003eThe number of individual Uniting AgeWell staff, consumer representatives, clients, and external experts who participated in co-design and implementation activities was collected from anonymous attendance records, survey responses, and feedback forms.\u003c/p\u003e\n\u003ch4\u003eSurveys\u003c/h4\u003e\n\u003cp\u003eApproval to seek survey and focus group responses from staff in the test region was granted by the Flinders University Human Research Ethics Committee. Information was provided to all staff in the test region about the research, inviting participation in surveys and focus groups in hard copy and by text message to remote staff. An online survey link was sent by text message by Uniting AgeWell to staff. The survey reiterated information on the voluntary and non-identifiable nature of the survey, and the withdrawal process by closing the web browser or not submitting the survey response. By submitting the survey response, participants gave implied consent.\u003c/p\u003e\n\u003cp\u003eThe same process was used for the anonymous pre- and post-implementation surveys of staff knowledge, skills, and confidence. The surveys were developed for this study using Qualtrics software (28) adapted from the Mental Health Literacy (MHL) (29, 30) measures, consisting of brief items (e.g., \u0026ldquo;Mental health is a normal part of ageing\u0026rdquo;, or \u0026ldquo; It\u0026rsquo;s best not to talk about issues related to mental health, as they might get upset\u0026rdquo;) that tested knowledge and beliefs aligned with staff roles in home care ( Supplementary File 1). Staff were reminded once to complete the survey via text message or email within two weeks. Anonymous staff feedback surveys at the mid-point and end point of the test phase were also distributed online via Qualtrics software, with similar time frames and reminders (Supplementary File 1 ).\u003c/p\u003e\n\u003ch4\u003eFile audit\u003c/h4\u003e\n\u003cp\u003eA file audit was conducted by UA, extracting non-client data from a data warehouse to maintain confidentiality according to privacy and data security requirements. A Structured Query Language (SQL) Script was applied to the data in the clinical management system, with search terms related to possible mental health issues (which were identified by the PAG, see Supplementary File 2). This data was collected at two time points \u0026ndash;during the 10 weeks immediately preceding the pilot (baseline), and during the 10-week test phase.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFocus Groups\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwo focus groups were conducted after the testing phase, one with HCWs and one with office-based staff. The questions were adapted from Participants were invited in-person and by text messages from Uniting AgeWell to join a focus group interview, with those volunteering to participate having the process of consent, recording, withdrawal, and de-identification of transcripts explained and the opportunity to sign a consent form at the start of the interview. \u003cem\u003e\u0026nbsp;\u003c/em\u003eDe-identified transcripts of the discussions were uploaded to NVivo 14 (31) and coded independently by two researchers (RH and LdlP) using the CFIR framework (32). Any disagreements were resolved by discussion and involvement of a third person (TW). (Supplementary File 3.)\u003c/p\u003e\n\u003ch4\u003eCo-design workshops and other data\u003c/h4\u003e\n\u003cp\u003eWritten notes and summaries from the workshops, extracts of written comments and synthesis from feedback surveys, emails, meetings with staff, and minutes of meetings of the research group and PAG were de-identified and uploaded to NVivo 14 (31) and coded in the same way using the CFIR framework (32).\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAnalysis and Evaluation\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eA concurrent mixed-methods design (33) collected qualitative and quantitative data pre-, during, and after the implementation of TMH. The Standards for Reporting Implementation Studies (StaRI checklist) (34) was used to assess the quality of this study (see Supplementary File 3).\u003c/p\u003e\n\u003cp\u003eA deductive framework analysis identified qualitative data from focus groups and comments in surveys, feedback, field notes, and meeting records using the online guide to coding and analysis of the key constructs of CFIR (35). An inductive analysis identified barriers and facilitators. The components of relevance to this study were 1) the characteristics of the individuals involved in the implementation, 2) the aspects of the inner setting and outer setting of the implementation study, 3) the characteristics of the intervention, and 4) the process of implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcess evaluation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrimary measures for the process evaluation were the adoption of the protocols by staff and the effectiveness of training and systems changes on staff mental health literacy. Secondary measures of reach, implementation, and maintenance of the protocols for the questions used in focus groups for staff, and in the analysis of transcripts, documents, and text comments in survey responses, meeting and field notes were guided by the CFIR framework (24, 32) . Quantitative and qualitative data were collected to examine the contextual factors affecting the outcomes. The measures, data sources and the associated methods of analysis corresponding with each dimension in the RE-AIM framework are outlined in Table 2.\u003c/p\u003e\n\u003cp\u003eTable 2. Dimensions of the RE-AIM framework and measures identified to evaluate the Talking Mental Health Project\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAim:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eto improve identification of mental health needs and improve access to support services for older recipients of aged care services living in the community with mental health needs.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDimensions of RE-AIM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eAdoption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eUptake of new processes:\u003c/p\u003e\n \u003cp\u003eQuantitative:\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eDe-identified file audit pre and post-implementation\u003c/li\u003e\n \u003cli\u003eNumbers of clients where screening and identification processes applied.\u003c/li\u003e\n \u003cli\u003eNumbers of elevation processes used\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eUniting AgeWell reports of use of protocols from the\u0026nbsp;client management system and digital file audit word search from a\u0026nbsp;data warehouse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eComparison of numbers of reports, assessments, and use of escalation process pre and post-testing phase\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDescriptive statistics of the\u0026nbsp;proportion of clients identified and responses by staff\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eEffectiveness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eMental health literacy and confidence of staff:\u003c/p\u003e\n \u003cp\u003eQuantitative and qualitative:\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eStaff survey of change in mental health knowledge, skills, and confidence and written comments\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003ePre- and post-pilot surveys of knowledge skills and confidence of staff (Qualtrics)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eDescriptive statistics: compare changes in knowledge, skills, and confidence in talking about mental health.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eQualitative analysis of comments\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eReach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eEngagement and retention of participants:\u003c/p\u003e\n \u003cp\u003eQuantitative: numbers and types of staff and clients involved in each aspect of the project\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eAttendance records, surveys, and field notes on participation for co-design, pilot, surveys, and training for staff, clients, and experts \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eRetention over the time of the project and reasons for variations or engagement levels\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eBarriers and facilitators, degree of acceptability, feasibility of the project:\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eQualitative: identification of factors influencing implementation for participants\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eQuantitative: feedback surveys from staff\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eFocus group transcripts and free text comments were provided via surveys, notes, emails, and meeting records to identify feedback from staff and advisory group on implementation.\u003c/p\u003e\n \u003cp\u003eMid-point and end of pilot surveys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eQualitative analysis based on CFIR framework of contextual and implementation characteristics and inductive analysis of other themes in the data.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBarriers and facilitators identified.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDescriptive statistics.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eMaintenance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003eImprovements and expected ongoing use:\u003c/p\u003e\n \u003cp\u003eQualitative: suggested improvements and future intentions, sustainment over time\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eFocus groups, field notes, text comments in surveys to identify improvements and intentions to maintain implementation.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFile Audit of use of protocols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eQualitative analysis on suggested improvements intentions identified and observations by the implementation team on feedback and review mechanisms.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSustained use of protocols\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe characteristics of the 157 individual participants during each phase of the TMH study are in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants in TMH study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of individuals\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of participation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-implementation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDuring implementation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePost Implementation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e* 7 Individual non-staff participating across a range of TMH activities\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNon-staff n\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn Project advisory group and co-design workshops\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExternal clinical experts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsumer representatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClients n\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCo-design workshops\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e*150 Individual Staff participating across a range of TMH activities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff n\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProject Advisory Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff n\u0026thinsp;=\u0026thinsp;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCo-design workshop 1\u0026amp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff n\u0026thinsp;=\u0026thinsp;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline Survey of Mental Health Literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff n\u0026thinsp;=\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-pilot survey Mental Health Literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff n\u0026thinsp;=\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFeedback surveys\u003c/p\u003e \u003cp\u003eMid-point\u003c/p\u003e \u003cp\u003eEnd pilot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff n\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e \u003cp\u003e* 2 incl in other activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFocus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e*Staff included in other activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraining\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnline and\u003c/p\u003e \u003cp\u003eIn-person sessions 113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOffice staff:\u003c/p\u003e \u003cp\u003eMHFA 23\u003c/p\u003e \u003cp\u003eOPMHFA 24\u003c/p\u003e \u003cp\u003eRefresher 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e*Total Participants in implementation activities N\u0026thinsp;=\u0026thinsp;157\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote. * Participants who were involved in several activities were only counted once overall. HCW\u0026thinsp;=\u0026thinsp;Home Care Workers. MHFA\u0026thinsp;=\u0026thinsp;Mental Health First Aid Training. OPMFA\u0026thinsp;=\u0026thinsp;Older Person\u0026rsquo;s Mental Health First Aid Training. Refresher\u0026thinsp;=\u0026thinsp;Refresher training.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eResults in relation to the RE-AIM Dimensions:\u003c/h2\u003e \u003cp\u003eIn the context of the number of total clients in the relevant catchment area remaining similar across the baseline (pre-pilot) and pilot phases (only a 1.96% increase in clients from baseline to pilot), results in relation to the RE-AIM dimensions:\u003c/p\u003e \u003cp\u003eAdoption\u003c/p\u003e \u003cp\u003eKey indicators obtained from the client management systems data (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) confirmed that the TMH protocols were well adopted by staff. Most notably, there was almost a fourfold increase in the number of client quality-of-life assessments administered via the Quality of life- Aged Care Consumers (QOL-ACC) instrument (which measures both health-related and psychosocial aspects of quality of life) from baseline (8.7% of total care plan assessments) to the pilot phase (35.8% of care plan assessments). The QOL-ACC was used 294.67% more often in the pilot period (296 times) as compared to the baseline period (75 times), demonstrating excellent adoption.\u003c/p\u003e \u003cp\u003eThe new reporting system implemented by HCWs at the end of their shifts during the 10-week testing phase resulted in 24,181 reports being generated. Of these reports, there were 275 instances across 149 clients (5% of total clients) where HCWs reported \u0026ldquo;Not Good/Unmet Needs\u0026rdquo;. This routine use of regular reports provided office-based staff with alerts (607 supervisor reviews) where a wide range of health concerns were noted. They reviewed care plans and case notes, then decided if they needed to elevate the response to check in with the client, assess needs, and refer for interventions where needed, indicating excellent adoption and consistent reporting.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eData extracted from client management system reports for the selected pilot region\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eData extracted\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTesting phase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of clients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2955\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncrease 1.96%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of QOL-ACC assessments completed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncrease 294.67%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Care plan assessments completed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e859\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e827\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDecrease 3.73%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of welfare check-ins conducted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e909\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncrease 16.28%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of client reports completed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24,181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent uptake of reporting protocol\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of supervisor reviews generated due to mental health and well-being concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e607\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReporting of additional information resulted in further clinical review\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of additional information (Dated notes) provided to office staff with further information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e523\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOf these 523 notes, 319 notes (60%) included the mental health-related key search words, indicating that 60% of the reported concerns were related to mental health and well-being.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of clients with at least 1 supervisor review generated due to mental health and well-being concerns?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11% of all clients had a review generated in the pilot period due mental health and well-being concerns\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of times \u0026ldquo;Not Good/Unmet Needs\u0026rdquo; was reported relating to mental health and well-being concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9% of the total number of clients in the pilot period\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFile Audit results revealed no increase in usual care plan reviews and related assessments between the baseline (n\u0026thinsp;=\u0026thinsp;859) and the testing phase n\u0026thinsp;=\u0026thinsp;827). This was due to fewer clients being due for annual care plan reviews during the pilot period. Due to this timing relating to annual reviews, Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows a decrease in the number of intake assessments and care plans during the testing phase (n\u0026thinsp;=\u0026thinsp;309) compared to baseline (n\u0026thinsp;=\u0026thinsp;486). However, the overall number of assessments increased in the testing phase due to introducing the reporting protocol for HCWs (total baseline assessments\u0026thinsp;=\u0026thinsp;486; total testing phase assessments\u0026thinsp;=\u0026thinsp;584). The overall ratio of mental health-related terms identified per assessment remained relatively stable at around 1.3 at the baseline and testing phase for office-based staff assessments. The ratio of mental health terms/reports for HCW reports during the testing phase was 1.08, indicating that HCWs were regularly referring to mental health-related issues in the text accompanying \u0026ldquo;Not good/Unmet Needs\u0026rdquo; reports\u003c/p\u003e \u003cp\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e Here).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of file audit for mental health terms at baseline and during the pilot period\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eText search for mental health terms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTesting phase\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOffice-based staff assessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e309\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWord Count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e405\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRatio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHCW assessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e275\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWord Count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e298\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRatio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e584\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWord Count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e703\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEffectiveness\u003c/p\u003e \u003cp\u003eData from 59 completed baseline staff surveys indicated that 50% of staff had adequate knowledge of the mental health needs of older people, and 81% were confident of what to do when they were concerned about a client\u0026rsquo;s mental health and well-being. Due to the anonymity of the surveys and the lack of matching between pre- and post-test responses, direct comparisons could not be made. However, post-test phase survey data (n\u0026thinsp;=\u0026thinsp;25 completed surveys) and qualitative feedback from the training sessions (n\u0026thinsp;=\u0026thinsp;24) indicated that staff generally perceived their participation in TMH as having increased their mental health knowledge and confidence. For example, responses to the post testing phase survey indicate increased skills in talking about mental health (88% agreed), improved knowledge about the mental health needs of older people (69% agreed), and more than two-thirds of participants reported increased confidence in talking with clients about mental health (72% agreed). Staff provided feedback that the training was enjoyable and added confidence to talk about mental health, thereby adding value to their roles.\u003c/p\u003e \u003cp\u003eImplementation of the full TMH process from report to referral (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) resulted in the initiation of 19 client check-ins by office staff during the testing phase, with all alerts raised followed up after the formal data collection period. This reflects a time lag in the completion of check-ins by office staff due to the initial high number of unnecessary supervisor alerts, but provides an indicator of the sustainment of the modified protocol use.\u003c/p\u003e \u003cp\u003eReach\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the activities of a total of 157 participants in the development and implementation of the TMH project. Additionally, all staff (n\u0026thinsp;=\u0026thinsp;188) of the pilot region used TMH in their regular work processes, with 150 individuals participating in at least one implementation activity (co-design workshops, surveys, training, feedback, and focus groups). Those involved in co-design and survey feedback reported appreciation for being included and valued the opportunity to voice their opinions. The staff training was enjoyed by almost all (96%) as being relevant, the right amount of time (100%), and well delivered (98%).\u003c/p\u003e \u003cp\u003eMembers of the PAG (5 non-staff, 2 staff, 6 researchers), together with 34 staff and two clients of Uniting Age Well, were involved in co-designing the protocols for implementation and contributed expertise, advice, and ongoing commitment to the project implementation. The PAG members reported that their involvement was purposeful and inclusive and addressed an issue of concern to them, which achieved positive results. The clients were pleased to share their perspectives, and that the provider was addressing an important area of need for older people.\u003c/p\u003e \u003cp\u003eImplementation and Maintenance:\u003c/p\u003e \u003cp\u003eAccording to participants, despite some initial technical difficulties with the reporting and review protocols, the implementation process was well organised and met all milestones in the project plan within a tight timeframe. The rapid-cycle implementation approach enabled the project team to respond quickly to feedback and make changes to the protocols and system settings. PAG oversight provided advice on mental health training and assessments and refinements to the protocols, while the co-design process engaged a range of perspectives to identify acceptable processes, and the involvement of all staff in a home care region tested the feasibility of the protocols in the real world.\u003c/p\u003e \u003cp\u003eQuotes from staff about their experience of the implementation process are presented in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. The key concerns and areas for improvement identified by staff included 1) the desire for greater input into project planning, 2) concerns around increased workload arising from reviewing HCW reports, 3) a lack of a clear communication method from office staff to HCWs following a report to \u0026ldquo;close the loop\u0026rdquo; and 4) challenges in communication and system implementation given the remote nature of HCW work, and few opportunities for direct contact with peers and supervisors.\u003c/p\u003e \u003cp\u003eThe TMH project achieved significant uptake of the protocols and offered effective training to staff on older people\u0026rsquo;s mental health. The embedding of protocols into existing systems was acceptable to most staff, and all staff of the test site used TMH as part of their daily work. Clients with mental health concerns were appropriately identified and followed up, resulting in added support and monitoring. The number of referrals for interventions was not collected.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of qualitative data collected from focus groups, survey comments, and notes of meetings, using the constructs of CFIR for analysis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstructs of CFIR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuotes from staff\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOverall summary of data\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOuter context: policy, social needs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;If we don't focus on mental health at all, we will be out of touch with the world and people\u0026rdquo; HCW1\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;It's about meeting needs. It's about valuing and respecting the individual\u0026rdquo; OS1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStaff understood the purpose of focusing on the mental health needs of older people and the required national quality standards reporting.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInner setting: culture, structure, and communication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;There's not enough of that direct support for the carers\u0026rdquo; OS2\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Carers are feeling a distance from management\u0026rdquo; HCW2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe structure of home care services (HCWs and office-based staff, and managers) was seen as a barrier to communication and support generally.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndividual characteristics: knowledge, stage of change, self-efficacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Now we have a focus, we have a vision, that we just go there knowing what mental health is. And now we sort of understand it\u0026rdquo; HCW3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe training and simple reporting systems helped HCWs understand client needs and clarified their roles. This facilitated feedback about clients to office-based staff.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntervention Characteristics: adaptability, complexity, design\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;It's not complicated to use but it is very time-consuming\u0026rdquo; OS2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOffice-based staff experienced an increase in workloads, with reports to be reviewed and the need for flexibility in assessments.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcess of implementation: engagement, roll out, and planning\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;It was a brand-new idea so there's going to be teething problems. It\u0026rsquo;s to be expected\u0026rdquo;. OS 4\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;We don't know if anyone even reads them (the reports)\u0026rdquo; HCW1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhile some staff saw the project as \u0026ldquo;really productive\u0026rdquo; increasing communication between staff, others reported not being involved enough in the planning and rollout and not getting feedback on the reports.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcess of implementation: Reflecting and evaluation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(It) would be good for this project to go on, to move forward\u0026rdquo; HCW4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhile the project was seen as \u0026ldquo;proactive\u0026rdquo; and \u0026ldquo;innovative\u0026rdquo;, staff offered suggestions for improvement: further simplification, consistency in feedback to HCWs, flexibility with assessment processes, and broadening the use of the reporting to include all concerns identified by HCWs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: OS\u0026thinsp;=\u0026thinsp;Office Staff; HCW\u0026thinsp;=\u0026thinsp;Home Care Worker\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResults are summarised against the primary and secondary measures using the RE-AIM framework in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of results of Talking Mental Health project against RE-AIM primary and secondary measures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eResults for Primary measures of RE-AIM framework\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdoption\u003c/b\u003e: There was significant uptake and use of protocols by staff during the pilot period\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEffectiveness\u003c/b\u003e: Increased mental health literacy (MHL) and confidence of staff in talking about mental health\u003c/p\u003e \u003cp\u003eIncreased identification of mental health concerns and support for clients to access interventions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResults for Secondary measures of RE-AIM framework\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReach\u003c/b\u003e: 157 people (both staff and non-staff stakeholders) participated in the development and implementation of TMH\u003c/p\u003e \u003cp\u003eproject\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImplementation process\u003c/b\u003e: Met all milestones. A collaborative effort drove implementation, and feedback from staff identified improvements needed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFacilitators for staff\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- TMH has simple tools that fit in with work processes, and good training is provided\u003c/p\u003e \u003cp\u003e- Involvement in co-design and implementation was appreciated\u003c/p\u003e \u003cp\u003e- TMH improved feedback about clients to office staff by HCWs\u003c/p\u003e \u003cp\u003e- TMH is an innovative approach to meet needs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBarriers for staff\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- Insufficient involvement in adapting their processes to the TMH steps\u003c/p\u003e \u003cp\u003e- Streamlining of intake system is needed to reduce paperwork\u003c/p\u003e \u003cp\u003e- Insufficient communication about the process led to a lack of clarity for some staff\u003c/p\u003e \u003cp\u003e- More support for HCWs was desired to cope with their mental health and the demands of the job.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaintenance\u003c/b\u003e: Ongoing use of the protocols with suggested improvements and ongoing training needed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe implementation of TMH at the pilot site improved staff commitment to mental health and well-being and their skills in mental health, increased the uptake of evidence to better identify older clients within the community who have mental health concerns, and improved access to support for their well-being. The TMH project resulted in the successful co-design and 100% uptake and adoption of four key protocols by aged care staff at Uniting AgeWell. Due to the implementation of TMH, there was a fourfold increase in quality of life assessments (as they were integrated into the Uniting AgeWell processes), improved awareness, recognition and reporting of client mental health and well-being needs, including 9% of the total number of clients in the testing phase identified as having mental health and well-being concerns that were likely to not have been identified otherwise. Implementation efforts in health and aged care show the impact that complexity and contextual constraints have on outcomes. A recent review (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) found that while there were an increasing number of studies on the implementation of innovations in aged care, few focused on community aged care, few used implementation theory or frameworks, and only 15% involved consumers in the process. The key factors that were found to influence change included organisational culture and resources, capabilities of staff, and stakeholder engagement in implementation strategies. The current study of the TMH project was designed with these factors in mind and successfully implemented the new TMH protocols, thus addressing recognised gaps in the literature for greater rigour, engagement with theory, and stakeholder engagement in implementing needed improvements in the growing community aged care sector.\u003c/p\u003e \u003cp\u003eIn TMH, a key focus was on facilitating an equal co-design process, where the expertise and perspectives of diverse participants were valued at all stages of the project, from design and refinement to evaluation of outcomes and improvements. Participants were paid for their participation either in hourly pay rates for staff, by invoice, or by gift cards based on hourly rates for clients and members of PAG. The use of co-design and World Caf\u0026eacute; (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) methods provided an opportunity to build on other ideas equally and to review the agreed key ideas. The collaborative co-design and partnership model between researchers, aged care managers and staff, external clinical experts, consumer representatives, and clients enabled planning and a responsive approach to implementation, modifications, and consideration of a range of perspectives. Evaluation results showed the co-design approach was well accepted and appreciated by participants, and the implementation of the TMH project resulted in a high take-up of the protocols by staff, better identification of clients with mental health concerns, and increased discussion of service options with clients. Indeed, because the TMH project was informed by and led by a cooperative implementation team, the new protocols were able to be embedded within an existing client reporting and management system. This led to the intervention being compatible with most existing processes and easy to use for most staff. The staff training (both online and in person) was well attended by staff, was well received and effective, and enabled HCWs to effectively identify clients who were experiencing mental health or well-being concerns. Office-based staff (e.g., care advisors and care coordinators) gained mental health literacy and confidence through education and training and used the new elevation process to review reports and decide on the appropriate response.\u003c/p\u003e \u003cp\u003eDespite considerable ongoing constraints on the aged care workforce and resources, the rapid assessment, evaluation, and implementation approach (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) in this study demonstrated the effective use of responsive planning, co-design, testing, and feedback approaches to engage and upskill staff and to design, implement, and embed new processes within existing systems. The introduction of the TMH program into daily community aged care work routines created initial technical and workload difficulties for staff, which required quick turnaround of changes to system issues and feedback to staff. This also identified the need for updated and streamlined processes. The rapid cycle implementation design was effective in making changes as needed to the protocols and system settings and provided opportunities for staff to give feedback and see changes made. The combination of mixed methods with a \u0026ldquo;rapid, iterative teams-based approach\u0026rdquo; recommended by McNall and colleagues (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) p.166, offered increased rigour to the evaluation. The feedback loops built into the implementation phases kept staff engaged and the implementation team focused on the adoption of the protocols.\u003c/p\u003e \u003cp\u003eThe model used to evaluate the implementation was similar to Morgan and colleagues (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), who used the CFIR to identify barriers and facilitators to implementing dementia care in primary health care in Canada. Like their study, the characteristics of the intervention, the local setting, and the process of implementation were found to be influential in the implementation of TMH. The constrained funding structure of home care and a mobile community-based workforce was identified as a barrier to communication and engagement of staff, yet the commitment of staff and the organisation to older people\u0026rsquo;s well-being was a strong driver of positive outcomes. A significant facilitator shared by staff and managers was the recognition of the need for a focus on mental health in community aged care. This recognition was aligned with both a response to older people\u0026rsquo;s needs and changes in the quality standards regulating home care services. Barriers in the local setting identified by staff included cross-staff role communication opportunities and funding constraints. For example, while HCWs have monthly in-person meetings, it was found that office-based staff rarely attended these. Further, as HCWs are a mobile community-based direct care workforce with heavy workloads, their ability to participate in the co-design workshops and provide feedback via surveys was limited.\u003c/p\u003e \u003cp\u003eLimitations and suggestions for further research\u003c/p\u003e \u003cp\u003eFuture research is needed on the maintenance and scalability of this approach to suit diverse older populations in different locations. The TMH project was implemented in one region (in a metropolitan area) only, and transferability to other locations and contexts cannot be assumed. The needs of older people and aged care staff in other areas may be different according to the local availability of services, cultural and linguistic background, and socio-economic status of clients and staff. Community aged care is one piece of the local context, and connections with other services are vital for coordinated responses. An appraisal of the context and readiness for implementation of the protocols would be needed if expanding the program for further roll-out (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). HCWs also indicated a desire for further focus on and greater support for their own mental health and well-being from managers, which should be a focus of future workforce research.\u003c/p\u003e \u003cp\u003eDespite the involvement of staff in the development of a mental health framework before the TMH project and ongoing communication about the co-design process and implementation of protocols, some staff perceived that communication about the changes was not sufficient. A process to gauge the reach and receptiveness to various communication strategies may be needed to improve the implementation process (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA pre- and post-implementation survey of knowledge, skills, and confidence of staff was planned to test the significance of changes in mental health literacy during the testing phase. This was not possible as different staff responded to each survey, and their responses could not be compared. This limited the measure of effectiveness. However, other measures, such as the significant uptake of the protocols and the appropriate identification of clients with mental health concerns, demonstrated that the training and use of protocols were effective. Improved communication about the need to complete both surveys may have improved the use of this measure.\u003c/p\u003e \u003cp\u003eThere were several limitations in the client management system, which reduced design options and adaptability for the reporting. The existing complicated assessment process for office-based staff increased documentation, and the overlap of items in various processes used outside of the TMH protocols was seen by staff as a barrier to implementation. We were unable to identify the number of referrals suggested to clients or provided formally, because of client privacy, as well as how referrals are captured in the clinical management system. As a result, a specific recommendation to provide a separate data field for referrals relating to mental health and well-being was made because of this TMH project. Finally, identifying the outcome of referrals was not possible due to privacy conditions, and was not the focus of the implementation outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e This study is one of the few examples of successful implementation of programs that exist in the aged care sector, which includes the elements of co-design with all affected parties, involvement of older people, and a concurrent process evaluation of a real-time innovation in community aged care services. The commitment of the organisation (Uniting AgeWell)) and collaborative involvement of the project team and staff were essential to drive the system changes and integration into the existing work processes. The rapid implementation of the four phases of the project, from governance and co-design to staff training, protocol testing, and refinement, was achieved through the significant investment from the provider. The methodology meaningfully involved older people and experts in the development process, and by embedding the protocols within daily work processes and simplifying processes as the protocols were tested, the project was able to reach all staff of the implementation site. Effective training increased the mental health literacy of staff and their capability to undertake their roles within the TMH protocols. The study also identified key areas for improvement that will inform the expansion of the TMH program across Uniting AgeWell services and in broader settings. This is a key opportunity to increase mental health awareness and integrate processes to improve the mental health and well-being of older people in the community.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eRE-AIM: Reach, Effectiveness, Adoption, Implementation, and Maintenance\u003c/p\u003e\n\u003cp\u003eCFIR: Consolidated framework for implementation research\u003c/p\u003e\n\u003cp\u003eUK: United Kingdom of Great Britain\u003c/p\u003e\n\u003cp\u003eUSA: United States of America\u003c/p\u003e\n\u003cp\u003eHCW: Home Care Worker\u003c/p\u003e\n\u003cp\u003eTMH: Talking Mental Health\u003c/p\u003e\n\u003cp\u003eUA: Uniting AgeWell\u003c/p\u003e\n\u003cp\u003ePAG: Project Advisory Group\u003c/p\u003e\n\u003cp\u003eMHL: Mental Health Literacy\u003c/p\u003e\n\u003cp\u003eSQL: Structured Query Language\u003c/p\u003e\n\u003cp\u003eMMAT: Mixed Methods Appraisal Tool\u003c/p\u003e\n\u003cp\u003eMHFA: Mental Health First Aid\u003c/p\u003e\n\u003cp\u003eOPMHFA: Older Persons Mental Health First Aid\u003c/p\u003e\n\u003cp\u003eQOL-ACC: Quality of life-Aged Care Consumer\u003c/p\u003e\n\u003cp\u003eOS: \u0026nbsp;Office Staff\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical approval for this study was granted by the Human Research Ethics\u0026nbsp;Committee of Flinders University, Australia (#6135) which is governed bythe Australian \u003cem\u003eNational Statement on Ethical Conduct in Human Research 2025, drawn from the principles of the Helsinki Declaration. Information sheets, consent forms and contact information for the researchers and the Ethics committee was provided to all staff to assist them in understanding the purpose and nature of the research, the consent and withdrawal process and how their anonymous or de-identified data would be used. Members of the research team met with staff in person, provided hard copies of information and consent forms, provided telephone and email contacts for further discussion and reiterated processes for voluntary consent and withdrawal from the research.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConsent for Publication of images: Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of Data:\u0026nbsp;All data generated or analysed during this study are included in this published article [and its supplementary information files]. Consent for the use of individual data did not allow for the public availability of transcripts due to privacy requirements.\u003c/p\u003e\n\u003cp\u003eCompeting Interests:\u0026nbsp;The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research was funded by\u0026nbsp;ARIIA (Aged Care Research \u0026amp; Industry Innovation Australia)\u0026nbsp;(R3GA00080)\u0026nbsp;with co-contributions by Uniting AgeWell to\u0026nbsp;support the aged care workforce’s capability and knowledge.\u003c/p\u003e\n\u003cp\u003eAuthors Contributions: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLdlP: Member of research team and PAG, coordinated the project and stakeholder engagement, reviewed the literature, sought ethics approval, revised the study protocol, developed training content, devised data collection and qualitative analysis, collected, analysed, and interpreted data, drafted and revised and submitted the manuscript\u003c/p\u003e\n\u003cp\u003eNB: Member of research team and PAG, coordinated the provider involvement, developed and monitored project tracking and data capture, developed staff training, led staff communication and engagement, extracted and analysed systems data and staff feedback, modified processes, developed project reports, and reviewed and revised the manuscript and gave final approval\u003c/p\u003e\n\u003cp\u003eRH: Member of research team and PAG, collected qualitative data, supported co-design processes, analysed data from transcripts, reviewed findings, and the manuscript\u003c/p\u003e\n\u003cp\u003eMC: Member of the research team, conceptualised the project, reviewed the literature, sought partners and funding, developed the study protocol, contributed intellectual content, revised the draft manuscript, and gave final approval\u003c/p\u003e\n\u003cp\u003eTW: Member of the research team and Chair of PAG, conceptualised the project, sought partners and funding, contributed intellectual content, managed the funding and reporting for the project, supervised the project coordinator, contributed the quantitative analysis, reviewed the draft and revisions of the manuscript, and gave final approval\u003c/p\u003e\n\u003cp\u003eAG: Member of the research team and PAG, contributed to the grant application and conceptualisation of the project, conceptualised and led the co-design process, sought stakeholder engagement and partners, contributed intellectual content, synthesized the co-design feedback, supervised the manuscript development, revisions, and gave final approval.\u003c/p\u003e\n\u003cp\u003eAcknowledgements:\u003c/p\u003e\n\u003cp\u003eWe wish to acknowledge the generous contribution of the consumer representatives, the clients, mental health experts, co-designers, and the staff of Uniting AgeWell in this implementation pilot. Their involvement and the commitment of Uniting AgeWell to improving the mental health of older people in the community made this study possible\u003c/p\u003e\n\u003cp\u003eWe gratefully acknowledge the essential contributions of the PAG: Claire Kelly from MHFA, Chris Dutton from Beyond Blue, Helen Mathews and Sherry-Ann Bailey from Uniting AgeWell, and community advisors Sue Aberdeen, Don and Robin Fergusson.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organisation. Mental Health of Older Adults Fact sheet Geneva: World Health Organisation; 2023 [updated 20/10/23. Available from: https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults.\u003c/li\u003e\n \u003cli\u003eAustralian Institute of Health and Welfare. Mental health in aged care Canberra: Australian Government; 2024 [updated 19/07/2024. Available from: https://www.aihw.gov.au/getmedia/c2f7f7a8-4182-4d25-bb41-419d222efe8d/mental-health-in-aged-care.pdf?v=20240730152118\u0026amp;inline=true\u003c/li\u003e\n \u003cli\u003eReynolds CF, Jeste DV, Sachdev PS, Blazer DG. Mental health care for older adults: recent advances and new directions in clinical practice and research. World Psychiatry. 2022;21(3):336-63. https://doi.org/10.1017/s0144686x21001896\u003c/li\u003e\n \u003cli\u003eReynolds CF, Cuijpers P, Patel V, Cohen A, Dias A, Chowdhary N, et al. Early Intervention to Reduce the Global Health and Economic Burden of Major Depression in Older Adults. Annual Review of Public Health. 2012;33(1):123-35. https://doi.org/10.1146/annurev-publhealth-031811-124544\u003c/li\u003e\n \u003cli\u003ePolacsek M, Boardman GH, McCann TV. Help‐seeking experiences of older adults with a diagnosis of moderate depression. International Journal of Mental Health Nursing. 2019;28(1):278-87. https://doi.org/10.1111/inm.12531\u003c/li\u003e\n \u003cli\u003eRoyal Commission into Aged Care Quality and Safety. Final Report: Care, Dignity and Respect. Canberra; 2021.\u003c/li\u003e\n \u003cli\u003eElshaikh U, Sheik R, Saeed RKM, Chivese T, Alsayed Hassan D. Barriers and facilitators of older adults for professional mental health help-seeking: a systematic review. BMC Geriatrics. 2023;23(1). https://doi.org/10.1186/s12877-023-04229-x\u003c/li\u003e\n \u003cli\u003eLavingia R, Jones K, Asghar-Ali AA. A Systematic Review of Barriers Faced by Older Adults in Seeking and Accessing Mental Health Care. J Psychiatr Pract. 2020;26(5):367-82. https://doi.org/10.1097/pra.0000000000000491\u003c/li\u003e\n \u003cli\u003eDepartment of Health and Aged Care. Home Care Packages program inclusions and exclusions. Canberra ACT: Australian Government; 2023.\u003c/li\u003e\n \u003cli\u003eProductivity Commission. Mental Health, Inquiry Report. 30 June 2020. Contract No. 95.\u003c/li\u003e\n \u003cli\u003eMental Health Australia. Report to the Nation. Canberra: Mental Health Australia; 2023 13 September 2023.\u003c/li\u003e\n \u003cli\u003eUnited Nations Economic Commission for Europe (UNECE). Policy Brief on Ageing: Mental Health of Older People Geneva: UNECE; 2024 [Available from: https://unece.org/sites/default/files/2024-06/ECE_PB29_Key_messages_En.pdf.\u003c/li\u003e\n \u003cli\u003eIskander-Reynolds A. Mental Health in Later Life. UK: Centre for Mental Health; 2024.\u003c/li\u003e\n \u003cli\u003eMiller JE, Cameron K. Progress on Mental Health Policy to Improve Service Access and Quality for Older Adults: Recent Successes, Proposed Legislation, and Strategies for Sustainability. Public Policy \u0026amp; Aging Report. 2024;34(2):39-43. https://doi.org/10.1093/ppar/prae007\u003c/li\u003e\n \u003cli\u003eDepartment of Health and Ageing. The strengthened aged care quality standards-final draft Canberra: Australian Government; 2023 [Final Draft Nov 2023:[Draft for consultation]. Available from: https://www.health.gov.au/sites/default/files/2023-12/the-strengthened-aged-care-quality-standards-final-draft-november-2023.pdf.\u003c/li\u003e\n \u003cli\u003eACIL Allen. National Mental Health Workforce: Labour Market Analysis: final report. Melbourne; 2022.\u003c/li\u003e\n \u003cli\u003eBatten G. Normalising mental illness in older adults is a barrier to care. Melbourne, Vic: Australian Institute of Family Studies; 2019 February 2019.\u003c/li\u003e\n \u003cli\u003eGoh AMY, Polacsek M, Malta S, Doyle C, Hallam B, Gahan L, et al. What constitutes \u0026lsquo;good\u0026rsquo; home care for people with dementia? An investigation of the views of home care service recipients and providers. BMC Geriatrics. 2022;22(1). https://doi.org/10.1186/s12877-021-02727-4\u003c/li\u003e\n \u003cli\u003eRobinson ES, Cyarto E, Ogrin R, Green M, Lowthian JA. Quality of life of older Australians receiving home nursing services for complex care needs. Health \u0026amp; Social Care in the Community. 2022;30(6):e6091-e101. https://doi.org/10.1111/hsc.14046\u003c/li\u003e\n \u003cli\u003eLuker JA, Worley A, Stanley M, Uy J, Watt AM, Hillier SL. The evidence for services to avoid or delay residential aged care admission: a systematic review. BMC Geriatrics. 2019;19(1). https://doi.org/10.1186/s12877-019-1210-3\u003c/li\u003e\n \u003cli\u003eProctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implementation Science. 2013;8(1):139. https://doi.org/10.1186/1748-5908-8-139\u003c/li\u003e\n \u003cli\u003eGlasgow RE, Battaglia C, McCreight M, Ayele RA, Rabin BA. Making Implementation Science More Rapid: Use of the RE-AIM Framework for Mid-Course Adaptations Across Five Health Services Research Projects in the Veterans Health Administration. Frontiers in Public Health. 2020;8. https://doi.org/10.3389/fpubh.2020.00194\u003c/li\u003e\n \u003cli\u003eCreswell John W. Designing and conducting mixed methods research. 2nd ed. ed. Plano Clark VL, editor. Los Angeles: Los Angeles : SAGE; 2011.\u003c/li\u003e\n \u003cli\u003eDamschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science. 2009;4(1):50. https://doi.org/10.1186/1748-5908-4-50\u003c/li\u003e\n \u003cli\u003eWoodward A. Mental Health and Wellbeing Framework and Suicide Prevention Action Plan: Report commissioned by Uniting AgeWell. Melbourne, VIC: Uniting AgeWell; 2019.\u003c/li\u003e\n \u003cli\u003eGoh AMY, Doyle C, Gaffy E, Batchelor F, Polacsek M, Savvas S, et al. Co-designing a dementia-specific education and training program for home care workers: The \u0026lsquo;Promoting Independence Through Quality Dementia Care at Home\u0026rsquo; project. Dementia. 2022;21(3):899-917. https://doi.org/10.1177/14713012211065377\u003c/li\u003e\n \u003cli\u003eThe World Cafe. World Cafe Method California: The World Cafe Community Foundation; 2024 [Available from: https://theworldcafe.com/key-concepts-resources/world-cafe-method/.\u003c/li\u003e\n \u003cli\u003eQualtrics. Qualtrics XM Platform. 2024 ed. Provo Utah: Qualtrics; 2024.\u003c/li\u003e\n \u003cli\u003eJorm AF. Mental health literacy: empowering the community to take action for better mental health. Am Psychol. 2012;67(3):231-43. https://doi.org/10.1037/a0025957\u003c/li\u003e\n \u003cli\u003eWei Y, McGrath PJ, Hayden J, Kutcher S. Mental health literacy measures evaluating knowledge, attitudes and help-seeking: a scoping review. BMC Psychiatry. 2015;15(1). https://doi.org/10.1186/s12888-015-0681-9\u003c/li\u003e\n \u003cli\u003eLumivero. NVivo (Version 14). (2023).\u003c/li\u003e\n \u003cli\u003eDamschroder LJ, Reardon CM, Widerquist MAO, Lowery J. The updated Consolidated Framework for Implementation Research based on user feedback. Implementation Science. 2022;17(1). https://doi.org/10.1186/s13012-022-01245-0\u003c/li\u003e\n \u003cli\u003eCreswell JW, Guetterman TC. Educational research : planning, conducting, and evaluating quantitative and qualitative research. Sixth edition. ed. New York, NY: Pearson; 2019.\u003c/li\u003e\n \u003cli\u003ePinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, et al. Standards for Reporting Implementation Studies (StaRI) Statement. BMJ. 2017:i6795. https://doi.org/10.1136/bmj.i6795\u003c/li\u003e\n \u003cli\u003eCFIR Research team for clinical management research. CFIR Guide Ann Arbor, MI: VA Ann Arbor Healthcare System; 2024 [Available from: https://cfirguide.org/evaluation-design/.\u003c/li\u003e\n \u003cli\u003eWindle A, Marshall A, de la Perrelle L, Champion S, Ross PDS, Harvey G, et al. Factors that influence the implementation of innovation in aged care: a scoping review. JBI Evidence Implementation. 2024: https://doi.org/10.1097/xeb.0000000000000407\u003c/li\u003e\n \u003cli\u003eSieh M. Guidelines for conversations that matter California: The World Cafe; 2020 [Available from: https://theworldcafe.com/.\u003c/li\u003e\n \u003cli\u003eHoldsworth LM, Safaeinili N, Winget M, Lorenz KA, Lough M, Asch S, et al. Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU. Implementation Science. 2020;15:1-12. https://doi.org/10.1186/s13012-020-0972-5\u003c/li\u003e\n \u003cli\u003eMcNall M, Foster-Fishman PG. Methods of rapid evaluation, assessment, and appraisal. American journal of evaluation. 2007;28(2):151-68. https://doi.org/10.1177/1098214007300895\u003c/li\u003e\n \u003cli\u003eMorgan D, Kosteniuk J, O\u0026rsquo;Connell ME, Kirk A, Stewart NJ, Seitz D, et al. Barriers and facilitators to development and implementation of a rural primary health care intervention for dementia: a process evaluation. BMC Health Services Research. 2019;19(1). https://doi.org/10.1186/s12913-019-4548-5\u003c/li\u003e\n \u003cli\u003eDomlyn AM, Scott V, Livet M, Lamont A, Watson A, Kenworthy T, et al. R\u0026thinsp;=\u0026thinsp;MC2 readiness building process: A practical approach to support implementation in local, state, and national settings. Journal of Community Psychology. 2021;49(5):1228-48. https://doi.org/10.1002/jcop.22531\u003c/li\u003e\n \u003cli\u003eZhao X, Toronjo H, Shaw CC, Murphy A, Taxman FS. Perceived communication effectiveness in implementation strategies: a measurement scale. Implementation Science Communications. 2022;3(1). https://doi.org/10.1186/s43058-022-00284-4\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Rapid-cycle implementation, process evaluation, co-design, mental health, protocols, stakeholders, aged-care","lastPublishedDoi":"10.21203/rs.3.rs-6730629/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6730629/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eThere is evidence that early intervention addressing older adults’ mental health needs can improve health outcomes and reduce the risk of critical events. However, these needs are not adequately addressed across the aged care system due to factors such as stigma, capacity, and access barriers. This study co-designed, implemented, and evaluated a pilot program, ‘Talking Mental Health’, to promote the uptake of mental health evidence into routine community aged care services in Australia.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eWe co-designed the Talking Mental Health program’s formal organisational protocols as a key implementation strategy and used a rapid-cycle implementation, assessment, and adaptation methodology based on the RE-AIM framework. A mixed methods process evaluation used the Consolidated Framework for Implementation Research (CFIR) to identify facilitators and barriers to the implementation process. Data were collected from organisational systems on the use of the protocols, and from surveys and focus groups with staff, people with lived experience, and experts. \u0026nbsp;Descriptive statistics assessed the degree of adoption and effectiveness of the protocols, and qualitative methods identified characteristics influencing the uptake of the program.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eThe analysis and evaluation identified that the implementation of Talking Mental Health was effective, with modified protocols adopted well by staff to identify older people with mental health needs and improve care and access to support. \u0026nbsp;The evaluation identified key contextual and implementation factors that affect the successful adoption of strategies to enhance the uptake of evidence in community aged care.\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eThe findings indicate that successful uptake of the Talking Mental Health program in community aged care requires 1) the alignment of external and organisational strategies with staff concerns for clients, 2) leaders to demonstrate commitment to addressing client and staff needs and 3) the process to involve stakeholders, with clear communication and easy-to-use strategies for implementation. Future research should examine how to scale this approach to other aged care settings and sustain the use of the Talking Mental Health and other mental health protocols to improve access to mental health interventions for older people.\u003c/p\u003e","manuscriptTitle":"Talking Mental Health in home care services for older people: implementation and process evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-04 11:12:33","doi":"10.21203/rs.3.rs-6730629/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-07-31T15:41:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-22T03:24:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"311791980631621502650726966946872134219","date":"2025-07-18T12:22:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-14T22:00:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"144053628008861086227767204667377842917","date":"2025-07-13T21:01:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"328331107645036784844572970316128910554","date":"2025-07-10T23:54:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"193341024138603359829020142155254147034","date":"2025-07-10T10:05:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-02T12:31:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-26T06:51:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-06T13:59:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-06T01:39:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-06-06T01:36:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf31e6f5-629a-4208-9784-4f54c7a1690a","owner":[],"postedDate":"July 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-04T11:12:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-04 11:12:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6730629","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6730629","identity":"rs-6730629","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}