Integration and continuity of primary care: polyclinics and alternatives - a patient-centred analysis of how organisation constrains care co-ordination

Background An ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level. Objectives To examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care. Methods Multiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care. Results Starting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care

Evidensbaserad metod eller praktisk verksamhet? Supported employment utan IPS

Evidence-based method or practical support for users? Supported Employment without IPS Since the Mental Health Reform of 1995, the social service in Sweden is required to offer ”meaningful activities” to persons with mental health impairments. This requirement has usually been met by the social service’s ”daily activities” centres, which do not have contact with the competitive labour market. ”Supported Employment” (SE) is a method which can be used to help people with mental health, neuropsychiatric or intellectual impairments to regular work places. Based on international research, the SE model ”Individual Placement and Support” (IPS) is recommended in national guidelines as an evidence-based method. However, IPS can be difficult to implement, since the model requires integrated teams, while in the Swedish system health care, social service and vocational rehabilitation belong to different sectors. Another reason is that subsidized forms of employment and internship are more usual in Sweden than in many other countries. This study investigates SE practices in three municipalities which do not follow all of the IPS model’s eight ”basic principles”. The results show that after 18 months many persons who had been totally without regular activities, or had access only to a daily activities centre, had some form of work or internship at regular workplaces. Twenty per cent had paid employment. The author interprets IPS as a ”packaging” of SE which the municipalities have ”translated” locally to offer SE activities which benefit users. This can also be seen as evidence-based practice (EBP), in which the best available research has been combined with the wishes of users and the professionals’ judgement of what is possible to offer in practice. Further research is needed concerning the value for users of prolonged internships which do not lead to paid employment.Socialtjänsten ska enligt SoL erbjuda "meningsfull sysselsättning" till personer med psykisk funktionsnedsättning. Insatserna har dock i huvudsak under lång tid varit begränsade till verksamheter utan koppling till ordinarie arbetsmarknad, s.k. "daglig verksamhet". "Supported Employment" (SE) är en metod för att i stället hjälpa personer med psykisk funktionsnedsättning, samt även personer med neuropsykiatrisk funktionsnedsättning eller utvecklingsstörning, att hitta sysselsättning på ordinarie arbetsplatser. Modellen "Individual Placement and Support" (IPS) har framhållits av Socialstyrelsen i nationella riktlinjer, framför allt utifrån internationell forskning. Svensk forskning har dock visat på svårig-heter med att implementera IPS, dels därför att IPS förutsätter integrerade ar-betsteam med psykiatrin, dels på grund av den stora förekomsten av subvention-erade sysselsättningsformer som praktik och lönebidrag. I denna studie under-söks SE-verksamheter i tre kommuner som inte uppfyller samtliga de åtta grundprinciperna som ställts upp för IPS. Resultaten visar att efter 18 månader hade många personer som tidigare helt saknat sysselsättning, eller som endast haft "daglig verksamhet", kunnat få sysselsättning i någon form och omfattning på ordinarie arbetsplatser. 20 % hade fått löneanställning, ofta på deltid och med lönebidrag. Författaren framhåller att IPS bör betraktas som en "förpackning" av den ursprungliga idén SE. De studerade kommunerna har olika förhållningssätt till IPS, men alla har låtit sig inspireras av SE och har skapat egna verksamheter till gagn för brukarna. Dessa lokalt anpassade verksamheter kan analyseras som lokala "översättningar" och kan även betraktas som en form av evidensbaserad praktik (EBP), där den bästa tillgängliga forskningen har kombinerats med bru-karnas önskemål och de professionellas bedömning av vad som är praktiskt att genomföra. Denna studie visar således att IPS-modellen kan översättas och an-passas till lokal SE-verksamhet, med goda resultat för brukarna. Ytterligare forskning behövs dock, framför allt kring nyttan för brukarna av praktik som inte leder till anställning

Creating Collaborative Forms and Meeting Places : Local Collaboration in Mental Health

Samverkan inom psykiatri/socialpsykiatri inbegriper organisationer och de professionella roller som utgår ifrån olika lagar och riktlinjer, organisatoriska strukturer samt teoretiska och professionella grunder. Syftet med denna studie är att ge en bild av hur en kommunal socialnämnd och en lokal psykiatrisk verksamhet kan arbeta med en långsiktig strategi för samverkan. Denna fallstudie granskar samverkan mellan psykiatrin och socialtjänsten i en kommun i Stockholms län. Ansatsen är organisationsteoretisk och belyser de strukturer och processer som samverkan innebär. De organisationer som berörs tillhör olika administrativa och politiska sektorer inom landsting respektive kommun och innefattar olika professionella inriktningar såsom läkare, socialsekreterare, sjuksköterskor, psykologer, kuratorer, arbetsterapeuter, boendestödjare, mentalskötare m.fl. Fallstudien omfattar dels en dokumentationsstudie över avtal och rutiner för samverkan, utvärderingar och andra typer av dokumentation samt en intervjustudie av personer med olika professionella roller inom respektive organisation. Resultaten visar att framgångsrik samverkan bygger på klara strukturer utifrån mandat från respektive organisations ledning samt processinriktade faktorer, framför allt behovet av gemensamma "arenor" som stöd till de direkta kontakter som behöver tas i arbetet med individuella patienter och klienter.Collaboration in the area of mental health involves organizations and professional roles with their basis in differing laws and guidelines, organizational structures and theoretical and professional foundations. The aim of this study is to examine the structures and processes involved in collaboration between the social service and providers of psychiatric care. Drawing on organizational theory concerning the nature of collaboration and factors which can hinder or assist successful collaboration, a case study has been constructed examining collaboration between a local psychiatric clinic in the region of Stockholm and the social service in a local community. The organizations concerned belong to different administrative and political sectors and involve professionals with various specialties such as psychiatrists, social welfare secretaries, nurses, psychologists, counsellors, occupational therapists and others. A study of formal agreements and routines for collaboration, evaluations and other forms of documentation, in combination with an interview study of persons with different professional roles in each respective organization, reveals the importance of a commitment to support collaboration from the management of each organization and the systematic creation and upholdning of meeting places for the various professions in order to support and facilitate cooperation concerning individual clients and patients

In the centre or caught in the middle? – Social workers’ and healthcare professionals’ views on user involvement in Coordinated Individual Plans in Sweden

Fragmentation of social service and heath care services has been given attention in many countries and a variety of strategies and models are used in attempts to remedy the problem. In a parallel development, demands have been made that users/patients should have more influence over their own care, and research has shown that user involvement can support the recovery process. This article focuses on how professionals view user involvement in collaborative efforts in care planning, using the Coordinated Individual Plan (CIP) in Sweden as an example. Since 2009, social service and health care agencies are required to draw up CIPs when they are judged to be needed, with the purpose of improveing the care process. An additional purpose is to increase users' involvement in their own care. Semi-structured interviews were conduced in 2019 with 20 professionals working within social service and health care agencies for people with mental health and/or substance abuse problems in the Stockholm region. Analysis was by qualitative content analysis. Findings show that professionals experience ambivalence concerning user involvement in care planning. On the one hand, they support the user's own demands of services and on the other hand, they correct the user's demands to fit the range of services and organisation of care. The user/patient's position is expressed as vulnerable, caugh between caregivers who often safeguard their own organisational duties and economical restrictions. These findings reflect the conflict predicted by Lipsky's theory of street-level cureaucracy. Professionals are expected to act as advocates for the user/patient, while at the same time exercising a controlling and gatekeeping function. The question is raised whether a model such as CIP provides sufficiently for factors which can counterbalance the power of the professionals relative to the user/patient in care planning

Diversity, complexity and ordinality: Mental health services outside the institutions—service users’ and professionals’ experience-based practices and knowledges, and new public management

In conjunction with the dismantling of psychiatric hospitals, social workers have been commissioned to help service users in their daily living in their homes and in the community. The consequences of these changes for experience-based knowledge and practices in their contexts remain relatively unknown. In this study, eighteen service users and the social workers they described as helpful for them were interviewed. The interviews were recorded, transcribed, and analyzed using Thematic Analysis. The following themes emerged: “Here, there and everywhere”, “Doing, being, becoming”, “Talking” and “Order, planning and improvisation” concerning the contradictions service users and professionals mentioned about their practices and the conditions imposed by managerial methods connected to New Public Management. Finally, “Spontaneous planned complexity” was chosen as our overarching theme to characterize the new knowledge and practices which have been developed. The displacement of the place for the encounter and the introduction of non-medicalized professions have allowed community-based practices and thus the co-creation and emergence of new knowledge about the service users as persons and the professionals as qualified professionals. The challenge remains for managers to have trust in their colleagues and not impose rigid rules, schematized methods, and repeated controls

The Coordinated Individual Plan – is this a solution for complex organizations to handle complex needs?

Persons with mental health problems and substance abuse often have complex needs requiring many kinds of help concurrently. In Sweden, an attempt has been made to counterbalance the effects of fragmentation by means of legislation on collaboration, requiring on the individual level the use of Coordinated Individual Plans (Sw. Samordnad Individuell Plan, SIP). The aim of the study is to explore collaboration as it is indicated in SIP and other case documentation with focus on how SIP is motivated, and what kind and degree of collaboration is indicated by the documentation. 12 individual case files have been studied in six local authorities and the results have been analyzed in relation to a regional collaboration agreement and local collaboration agreements. The results show unclear motivation for SIP and that SIP is primarily used for documentation of short-term planning. Use of SIP and participation in SIP appears also to be uneven. The authors characterize SIP as an unsystematic form of interagency meeting, with documentation indicating a relatively low to moderate level of collaboration. The authors question whether SIP is an optimal form for collaboration and suggest that more distinct models such as case management or multidisciplinary teams could be more effective