Key dimensions of collaboration quality in mental health care service networks

Islands in the stream: a qualitative study on the accessibility of mental health care for persons with substance use disorders in Belgium

Introduction

Persons with substance use disorders (SUD) make up a considerable proportion of mental health care service users worldwide. Since 2010, Belgian mental health care has undergone a nationwide reform ('Title 107') aiming to realize a mental health care system that fosters more intensive collaboration, strengthens the cohesion and integration across and between different services, and is more responsive to the support needs of all service users. Although persons with SUD were named as a prioritized target group, how this reform impacted the lives and recovery journeys of persons with SUD remains understudied. This study aims to investigate how persons with SUD, regardless of whether they have co-occurring mental health issues, experience the accessibility of mental health care in light of the 'Title 107' reform.

Methods

Data were collected by means of in-depth interviews with a heterogeneous sample of persons with SUD (n=52), recruited from five regional mental health networks in Belgium. In-depth interviews focused on experiences regarding (history of) substance use, accessibility of services and support needs, and were analyzed thematically.

Results

Five dynamic themes came to the fore: fragmentation of care and support, the importance of "really listening", balancing between treatment-driven and person-centered support, the ambivalent role of peers, and the impact of stigma.

Discussion

Despite the 'Title 107' reform, persons with SUD still experience mental health care services as 'islands in the stream', pointing to several pressing priorities for future policy and practice development: breaking the vicious cycles of waiting times, organizing relational case management, tackling stigma and centralizing lived experiences, and fostering recovery-promoting collaboration.

Unravelling collaborative governance dynamics within healthcare networks: a scoping review

In many countries, healthcare systems suffer from fragmentation between hospitals and primary care. In response, many governments institutionalized healthcare networks (HN) to facilitate integration and efficient healthcare delivery. Despite potential benefits, the implementation of HN is often challenged by inefficient collaborative dynamics that result in delayed decision-making, lack of strategic alignment and lack of reciprocal trust between network members. Yet, limited attention has been paid to the collective dynamics, challenges and enablers for effective inter-organizational collaborations. To consider these issues, we carried out a scoping review to identify the underlying processes for effective inter-organizational collaboration and the contextual conditions within which these processes are triggered. Following appropriate methodological guidance for scoping reviews, we searched four databases [PubMed (n = 114), Web of Science (n = 171), Google Scholar (n = 153) and Scopus (n = 52)] and used snowballing (n = 22). A total of 37 papers addressing HN including hospitals were included. We used a framework synthesis informed by the collaborative governance framework to guide data extraction and analysis, while being sensitive to emergent themes. Our review showed the prominence of balancing between top-down and bottom-up decision-making (e.g. strategic vs steering committees), formal procedural arrangements and strategic governing bodies in stimulating participative decision-making, collaboration and sense of ownership. In a highly institutionalized context, the inter-organizational partnership is facilitated by pre-existing legal frameworks. HN are suitable for tackling wicked healthcare issues by mutualizing resources, staff pooling and improved coordination. Overall performance depends on the capacity of partners for joint action, principled engagement and a closeness culture, trust relationships, shared commitment, distributed leadership, power sharing and interoperability of information systems To promote the effectiveness of HN, more bottom-up participative decision-making, formalization of governance arrangement and building trust relationships are needed. Yet, there is still inconsistent evidence on the effectiveness of HN in improving health outcomes and quality of care.

Exploring stakeholders' perceived problems associated with the care and support of children and youth with mental ill health in Sweden: a qualitative study

BACKGROUND

Care and support for children and youth with mental ill health have become more specialized and are provided by an increasing number of stakeholders. As a result, services are often fragmented, inefficient and unco-ordinated, with negative consequences for the service user and their family. Enhanced collaboration could lead to improved care and support but requires a shared understanding and a joint problem formulation between involved stakeholders to commence. The aim of this study was to explore different stakeholders' perceived problems associated with delivering care and support to children and youth with mental ill health and to discuss how the perceived problems relate to collaboration.

METHODS

A qualitative descriptive study was conducted, using short statements of perceived problems written by stakeholders involved in the care and support of children and youth with mental ill health during an inter-organizational workshop. The 26 stakeholders represented school and student health, primary health care, specialist care, social services, and different service user organizations. Data were collected during February 2020. Inductive content analysis with a summative approach was used when analysing the data.

RESULTS

The perceived problems were summarized in a model consisting of four main categories: Resources and governance; Collaboration and co-ordination; Knowledge and competence; and Stigma and confidence, containing 24 subcategories. These categories and subcategories were distributed over three levels: Societal level, Organizational level and Individual level. The perceived problems were shared on the category level but to some extent varied between stakeholder groups on the subcategory level. The perceived problems were either directly or indirectly related to collaboration.

CONCLUSIONS

The perceived problems often acted as barriers to achieving successful collaboration. The problems were distributed on all three levels in the developed model, indicating a complex problem. Even though the perceived problems were shared by stakeholders on an overall level, the findings indicate that the stakeholders did not have a completely shared understanding of the perceived problems, as they tended to focus on aspects most relevant to their own organization or perceptions. The challenge is to find which perceived problems are appropriate for inter-organization problem-solving and which can be solved within individual organizations.

Values and practice of collaboration in a mental health care system in the Netherlands: a qualitative study

BACKGROUND

To offer optimal care, the mental health system needs new routes for collaboration, involving both interprofessional and interorganizational aspects. The transition from intramural to extramural mental health care has given rise to new dynamics between public and mental health care, introducing a challenge for interprofessional and interorganizational collaboration. This study aims to determine values and expectations of collaboration and to understand how collaboration in mental health care organizations takes shape in daily practice.

METHODS

We conducted a qualitative study using semi-structured interviews and a focus group, in the setting of the Program for Mentally Vulnerable Persons (PMV). Data were analysed following thematic analysis.

RESULTS

We found three aspect that were considered important in collaboration: commonality, relationships, and psychological ownership. However, our findings indicate a discrepancy between what is considered essential in collaboration and how this materializes in day-to-day practice: collaboration appears to be less manageable than anticipated by interviewees. Our data suggest psychological ownership should be added as value to the interorganizational collaboration theory.

CONCLUSION

Our study offers a new definition of collaboration and adding "psychological ownership" to the existing literature on collaboration theory. Furthermore, we gained insight into how collaboration between different organizations works in practice. Our research points to a discrepancy between what all the partners find important in collaboration, and what they actually do in practice. Finally, we expressed ways to improve the collaboration, such as choosing between a chain or a network approach and acting on it and re-highlighting the goal of the Program Mentally Vulnerable persons.

Getting our hopes up: How actors perceive network effectiveness and why it matters

Health care's grand challenges, such as continuously increasing costs, challenge the sustainability of health systems. Purpose-oriented networks are considered a favorable mode of organization to address these grand challenges. Therefore, it is crucial that they are effective. While network effectiveness is a heavily theorized, multi-dimensional concept that is often measured as a perception of actors, little is known about how network actors perceive effectiveness in practice and how this influences their behavior. In this study, we explored how network actors perceive network effectiveness using 32 interviews with representatives from network member organizations and regulatory agencies actor, 28 h of network meeting observations, and 1.272 pages of documents such as meeting minutes and media outlets. Our results show that actors primarily see hard outcomes (e.g. changes in cost or quality of care) as effectiveness but given the temporal nature of these goals and difficulties quantifying them, they resort to the collaborative process as a proxy to assess effectiveness. Actors engage in networks to solve grand challenges. However, conforming to expectations and environmental pressures also play a substantial role for actors to (continue to) participate in networks. In the absence of hard outcomes, actors legitimize their continued participation in networks using the collaborative process of networks. Actors therefore take purpose-oriented networks for granted as a legitimate way of organizing. Besides attempting to solve grand challenges, networks thus also seem to be adopted because of powerful institutional rules that function as rationalized myths, to gain legitimacy. Future research should be aware of and further unravel the institutional pressures in networks.

Intersectoral and multisectoral approaches to enable recovery for people with severe mental illness in low- and middle-income countries: A scoping review

The needs of people with severe mental illness are complex and require a range of services embedded in well-coordinated systems of care to enable recovery, promote well-being and optimise social integration. The concept of recovery is strongly rooted in the centrality of multi and intersectoral systems of care, and, while multi and -intersectoral dimensions of mental health systems have been highlighted in analyses focusing on high-income regions, little has been elaborated in terms of these approaches in the recovery of people with severe mental illness (SMI) in low- and middle-income countries (LMICs). The aim of this review was to identify and describe multi and intersectoral approaches underpinning community-based SMI recovery interventions in LMICs. A scoping review was carried out following the following steps: (1) Objectives for the review were developed and refined; (2) A systematic search of databases (EbscoHost, PubMed, Google Scholar) and previous reviews were undertaken from 2012 to 2022, where relevant papers were identified; (3) Papers with a focus on SMI and recovery, a specific description of an intervention, located in LMICs, with explicit linkages between sectors, and published in English, were selected for inclusion; (4) Data were extracted and charted and (5) Findings were analysed and reported thematically. Thirty-six papers were included for analysis, from 18 countries, including qualitative studies, trials, desktop and secondary data reviews and case studies. Examples of multi- and intersectoral action included collaboration between healthcare and community support systems, collaboration in providing supported housing and supportive community spaces for recovery, and linkages between biomedical and social spheres of care. Barriers included the dominance of mental health professions in delivering care, community-based stigmatising attitudes towards SMI. Multi- and intersectoral collaboration for SMI recovery requires investments in financing, education and coordination by a governing body.

So Happy Together: A Review of the Literature on the Determinants of Effectiveness of Purpose-Oriented Networks in Health Care

While purpose-oriented networks are widely recognized as organizational forms to address wicked problems in health care such as increasing demands and expenditure, the associated literature is fragmented. We therefore reviewed empirical studies to identify the determinants of the effectiveness of these networks. Our search yielded 3,657 unique articles, of which 19 met our eligibility criteria. After backward snowballing and expert consultation, 33 articles were included. Results reveal no less than 283 determinants of effective health care networks. The majority of these determinants are processual and involving professionals from the operational level is particularly salient. In addition, most studies relate determinants to process outcomes (e.g., improved collaboration or sustainability of the network) and only a few to members' perception of whether the network attains its goals. We urge future research to adopt configurational approaches to identify which sets of determinants are associated with networks' ability to attain their goal of addressing wicked problems.

Use of generic social services and social integration of patients with a severe mental illness in Belgium: Individual and services network determinants

BACKGROUND

Patients with severe mental illnesses (SMI) have low levels of social integration, which could be improved if they used social services. To our knowledge, however, the extent to which they use generic social services remains unknown.

AIMS

We assessed the extent to which patients with SMI use generic social services and the factors that may drive that usage.

METHOD

In 2014, we carried out a multi-setting clustered survey of patients with severe mental disorders (n = 1,019, participation rate = 71%) and of services (n = 517, participation rate = 53%) in 19 networks of services, covering most of Belgium. On the one hand, we asked patients, amongst other, about their health condition, their social integration in the community, and their use of social services of different types. On the other hand, we asked each service to report on its relationships with other services in the services networks.

RESULTS

On average, patients' use of generic social services within the previous 6 months was low (6%-16%), with the exception of administrative services. There were few differences in usage according to the severity of patients' symptoms, but some differences according to gender and age were observed. Social integration was improved when generic social services were more central in the networks.

CONCLUSIONS

We suggest that generic social services should be more central in mental health services networks.

An integrative perspective on interorganizational multilevel healthcare networks: a systematic literature review

BACKGROUND

Interorganizational networks in healthcare do not always attain their goals. Existing models outline the factors that could explain poor network performance: governance; structure; and the alignment of professional, organizational and network levels. However, these models are very generic and assume a functional approach. We investigate available empirical knowledge on how network structure and governance relate to each other and to network performance in a multilevel context, to get deeper insight, supported with empirics, of why networks (fail to) achieve their goals.

METHOD

A systematic literature review based on a search of Web of Science, Business Source Complete and PubMed was executed in May 2021 and repeated in January 2022. Full papers were included if they were written in English and reported empirical data in a healthcare interorganizational setting. Included papers were coded for the topics of governance, structure, performance and multilevel networks. Papers from the scientific fields of management, administration and healthcare were compared. Document citation and bibliographic coupling networks were visualized using Vosviewer, and network measures were calculated with UCINET.

RESULTS

Overall, 184 papers were included in the review, most of which were from healthcare journals. Research in healthcare journals is primarily interested in the quality of care, while research in management and administration journals tend to focus on efficiency and financial aspects. Cross-citation is limited across different fields. Networks with a brokered form of governance are the most prevalent. Network performance is mostly measured at the community level. Only a few studies employed a multilevel perspective, and interaction effects were not usually measured between levels.

CONCLUSIONS

Research on healthcare networks is fragmented across different scientific fields. The current review revealed a range of positive, negative and mixed effects and points to the need for more empirical research to identify the underlying reasons for these outcomes. Hardly any empirical research is available on the effects of different network structures and governance modes on healthcare network performance at different levels. We find a need for more empirical research to study healthcare networks at multiple levels while acknowledging hybrid governance models that may apply across different levels.

What Matters for Evaluating the Quality of Mental Healthcare? Identifying Important Aspects in Qualitative Focus Groups with Service Users and Frontline Mental Health Professionals

Background

Evaluating quality in mental healthcare is essential for ensuring a high-quality experience for service users (SUs). Policy-defined quality indicators, however, risk misalignment with the perspectives of SUs and mental healthcare professionals (MHPs). There is value in exploring how SUs and frontline MHPs think quality should be measured.

Objectives

Our study objectives were to: (1) identify aspects that SUs and MHPs deem important for assessing quality in mental healthcare to help support attribute selection in a subsequent discrete choice experiment and (2) explore similarities and differences between SU and MHPs’ views.

Methods

Semi-structured qualitative focus groups (n = 6) were conducted with SUs (n = 14) and MHPs (n = 8) recruited from a UK National Health Service Trust. A topic guide was generated from a review of UK policy documents and existing data used to measure quality in mental healthcare in England. Transcripts were analysed using a framework analysis.

Results

Twenty-one subthemes were identified, grouped within six themes: accessing mental healthcare; assessing the benefits of care; co-ordinated approach; delivering mental healthcare; individualised care; and role of the person providing care. Themes such as person-centred care, capacity and resources, and receiving the right type of care received more coverage than others. Service users and MHPs displayed high concordance in their views, with minor areas of divergence.

Conclusions

We developed a comprehensive six-theme framework for understanding quality in mental healthcare from the viewpoint of the SU and frontline MHP, which can be used to help inform the selection of a meaningful set of quality indicators in mental health for research and practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-022-00580-0.

Physical Healthcare, Health-Related Quality of Life and Global Functioning of Persons with a Severe Mental Illness in Belgian Long-Term Mental Health Assertive Outreach Teams: A Cross-Sectional Self-Reported Survey

Research shows that care delivery regarding somatic health problems for patients with a severe mental illness (SMI) in community and mental health is difficult to establish. During the last decade, long term mental health outreach teams in Belgium were implemented to provide treatment and follow-up at home. This study aimed to map physical health status, care professionals, health related quality of life and global functioning in persons with SMI in Belgian long term outreach teams for mental health. Using a self-administered questionnaire, 173 persons, 58.1% female with a mean age of 48.3, were questioned. Our findings suggest an undertreatment of somatic comorbid conditions, with only half of physical health complaints being addressed. Although treatment rates for hypertension, when detected were high, treatment of respiratory complaints, pain and fatigue was lacking. Although the majority of respondents responded to have a GP or psychiatrist, contact rates were rather limited. Other disciplines, such as primary care nurses, when present, tend to have more contact with people with SMI. Notably, having regular contacts with GPs seems to improve physical health complaints and/or treatment. Being treated by an outreach team did not show significant correlations with physical health complaints and/or treatment suggesting a more proactive approach by outreach teams or primary care providers is desirable.

Selection of Pediatric Mental Health Quality Measures for Health System Improvement in British Columbia Based on a Modified Delphi Approach

BACKGROUND

The COVID-19 pandemic has highlighted the importance of mental wellbeing. The identification and implementation of quality measures can improve health outcomes and patient experience. The objective was to identify and define a core set of valid and relevant pediatric mental health quality measures that will support health system evaluation and quality improvement in British Columbia, Canada.

METHODS

The study consisted of four phases. First, a comprehensive database search identified valid pediatric quality measures focused on mental health and substance use (MH/SU). Second, the identified quality measures were mapped to focus areas, which were then prioritized by two stakeholder groups consisting of 26 members. Third, up to two representative measures for each prioritized focus area were pre-selected by an expert panel (n = 9). And fourth, a three-step modified Delphi approach was employed to (1) assess each quality measure on a 7-point Likert scale against three relevance criteria (representative of a quality problem, value to intended audience and actionable), (2) discuss the results, and (3) select and rank the most relevant measures. Forty-eight stakeholders were invited to participate; of those 24 completed the round 1 survey, 21 participated in the round 2 discussion and 18 voted in the round 3 selection and ranking survey. For round 1, consensus was determined when at least 70% of the response rates were within the range of five to seven. For round 3, Kendall's coefficient of concordance W was used as an estimator of inter-rater reliability.

RESULTS

One-hundred pediatric mental health quality measures were identified in the database search. Of those, 37 were mapped to ten focus areas. Pre-selection resulted in 19 representative measures moving forward to the Delphi study. Eleven measures met the consensus thresholds and were brought forward to the round 2 discussion. Round 3 ranking showed moderate to strong raters' agreement (Kendall's W = 0.595; p < 0.01) and resulted in the following five highest-ranked measures: level of satisfaction after discharge from inpatient admission due to MH/SU, number of patients experiencing seclusion or restraint, length of time from eating disorder referral to assessment, number of ED visits due to MH/SU, and number of readmissions to ED.

CONCLUSION

The selected core set of valid and relevant pediatric quality measures will support sustainable system change in British Columbia. The five top-ranked measures will be refined and tested for data collection feasibility before being implemented in the province.

Inter-organizational collaboration between healthcare providers

Across OECD countries, healthcare organizations increasingly rely on inter-organizational collaboration (IOC). Yet, systematic insight into the relations across different healthcare sectors is lacking. The aim of this explorative study is twofold. First, to understand how IOC differs across healthcare sectors with regards to characteristics, motives and the role of health policy. Second, to understand which potential effects healthcare executives consider prior to the establishment of the collaborations. For this purpose, a survey was conducted among a representative panel of Dutch healthcare executives from medium-sized or large healthcare organizations. Almost half (n = 344, 48%) of the invited executives participated. Our results suggest that differences in policy changes and institutional developments across healthcare sectors affect the scope and type of IOC: hospitals generally operate in small horizontal collaborations, while larger and more complex mixed and non-horizontal collaborations are more present among nursing homes, disability care and mental care organizations. We find that before establishing IOCs, most healthcare executives conduct a self-assessment including the potential effects of the collaboration. The extensive overview of policy developments, collaboration types and intended outcomes presented in our study offers a useful starting point for a more in-depth assessment of the effectiveness of collaborations among healthcare organizations.

Care coordination for severe mental health disorders: an analysis of healthcare provider patient-sharing networks and their association with quality of care in a French region

BACKGROUND

For patients with multiple and complex health needs, such as those suffering from mental health disorders, outcomes are determined by the combined actions of the care providers they visit and their interactions. Care coordination is therefore essential. However, little is known on links between hospitals providing psychiatric care and community-based care providers which could serve as a basis for the creation of formal mental care networks supported by recent policies. In this context, we first aimed to identify and characterize existing types of healthcare provider patient-sharing networks for severe mental health disorders in one French region. Second, we aimed to analyse the association between their characteristics and the quality of the care they provide.

METHODS

Patient flows among healthcare providers involved in treating severe mental health disorders in the Provence-Alpes-Côte-d'Azur region were extracted from the French national health data system, which contains all billing records from the social health insurance. Healthcare provider networks that have developed around public and private non-profit hospitals were identified based on shared patients with other providers (hospitals, community-based psychiatrists, general practitioners and nurses). Hierarchical clustering was conducted to create a typology of the networks. Indicators of quality of care, encompassing multiple complementary dimensions, were calculated across these networks and linked to their characteristics using multivariable methods.

RESULTS

Three main types of existing healthcare provider networks were identified. They were either networks strongly organized around the main hospital providing psychiatric care; scattered networks involving numerous and diverse healthcare providers; or medically-oriented networks involving mainly physician providers. Few significant associations between the structure and composition of healthcare provider networks and indicators of quality of care were found.

CONCLUSIONS

Our findings provide a basis to develop explicit structuring of mental care based on pre-existing working relationships but suggest that healthcare providers' patient-sharing patterns were not the main driver of optimal care provision in the context explored. The shift towards a stronger integration of health and social care in the mental health field might impact these results but is currently not observable in the administrative data available for research purpose which should evolve to include social care.