How size matters: exploring the association between quality of mental health services and catchment area size

Mental health service diversity and work disability: associations of mental health service system characteristics and mood disorder disability pensioning in Finland

PURPOSE

Public mental health services (MHS) are crucial in preventing psychiatric disability pensions (DP). We studied the associations between mood disorder DP risk and the characteristics of Finnish municipalities' MHS provision using the ESMS-R mapping tool and Finnish population registers, based on first-time granted mood disorder DPs between 2010 and 2015.

METHODS

The final data set included 13,783 first-time mood disorder DP recipients and 1088 mental health service units in 104 municipalities. We focused on five different MHS types: all MHS, outpatient care provision, local services without and with gatekeeping, and centralized services. Three factors for each MHS type were studied: service resources, richness, and diversity index. Negative binomial regression models were used in the analysis.

RESULTS

In all the municipalities, higher service richness and diversity regarding all MHS, outpatient care and local services with gatekeeping were associated with a lower DP risk. In urban municipalities, service richness was mainly associated with lower DP risk, and in semi-urban municipalities service diversity and resources were primarily associated with lower DP risk in outpatient care and local services with gatekeeping. In rural municipalities, DP risk indicated no association with MHS factors.

CONCLUSION

The organization and structure of MHS play a role in psychiatric disability pensioning. MHS richness and diversity are associated with lower mood disorder DP in specific societal contexts indicating their role as quality indicators for regional MHS. The diversity of service provision should be accounted for in MHS planning to offer services matching population needs.

Patterns of mental health services and mood disorder disability pensions: a standard comparison of Finland's three largest hospital districts

INTRODUCTION

Mental disorders are one of the most common and disabling health conditions worldwide. There is however no consensus on the best practice of system level mental health services (MHS) provision, in order to prevent e.g. mood disorder disability pensions (DPs). We analyzed the MHS provision between Finland's three largest hospital districts Helsinki and Uusimaa (HUS), Southwest Finland and Pirkanmaa, with known differences in mood disorder DP risk but presumably equal rates of mood disorder prevalence.

METHODS

We used public MHS data analyzed with the standardized DEscription and Evaluation of Services and DirectoriEs for Long Term Care (DESDE-LTC) mapping tool, focusing on all MHS, outpatient care provision, local services without and with gatekeeping, and centralized services. We also collected demographic data based on the European Socio-Demographic Schedule (ESDS). As a novel approach, the Gini-Simpson Diversity Index (GSDI) was calculated for the districts.

RESULTS

Evident differences were observed regarding the districts' MHS factors. As the hospital district with lower DP risk, HUS was characterized by the highest level of regional socioeconomic prosperity as well as high service richness and diversity. With a nationally average DP risk, Southwest Finland had the highest number of MHS personnel in full-time equivalents (FTE) per 100 000 inhabitants. Pirkanmaa, with a higher DP risk, had overall the lowest service richness and the lowest FTE of the three districts in all MHS, outpatient care and local services with gatekeeping.

CONCLUSIONS

Our findings indicate that greater richness and diversity of MHS, especially in outpatient and community-based settings, may serve as indicators of a balanced, high-quality service system that is more effective in preventing mood disorder DP and meeting the different needs of the population. In addition, the need for sufficient resourcing in all MHS and outpatient services is indicated. We suggest using diversity indices to complement the measuring and reporting of regional service variation.

Impact of the workforce allocation on the technical performance of mental health services: the collective case of Helsinki-Uusimaa (Finland)

BACKGROUND

Long-term mental health (MH) policies in Finland aimed at investing in community care and promoting reforms have led to a reduction in the number of psychiatric hospital beds. However, most resources are still allocated to hospital and community residential services due to various social, economic and political factors. Despite previous research focussing on the number and cost of these services, no study has evaluated the emerging patterns of use, their technical performance and the relationship with the workforce structure.

OBJECTIVE

The purpose of this study was to observe the patterns of use and their technical performance (efficiency) of the main types of care of MH services in the Helsinki-Uusimaa region (Finland), and to analyse the potential relationship between technical performance and the corresponding workforce structure.

METHODS

The sample included acute hospital residential care, non-hospital residential care and outpatient care services. The analysis was conducted using regression analysis, Monte Carlo simulation, fuzzy inference and data envelopment analysis.

RESULTS

The analysis showed a statistically significant linear relationship between the number of service users and the length of stay, number of beds in non-hospital residential care and number of contacts in outpatient care services. The three service types displayed a similar pattern of technical performance, with high relative technical efficiency on average and a low probability of being efficient. The most efficient acute hospital and outpatient care services integrated multidisciplinary teams, while psychiatrists and nurses characterized non-hospital residential care.

CONCLUSIONS

The results indicated that the number of resources and utilization variables were linearly related to the number of users and that the relative technical efficiency of the services was similar across all types. This suggests homogenous MH management with small variations based on workforce allocation. Therefore, the distribution of workforce capacity should be considered in the development of effective policies and interventions in the southern Finnish MH system.

Patterns of mental healthcare provision in rural areas: A demonstration study in Australia and Europe

INTRODUCTION

Mental healthcare systems are primarily designed to urban populations. However, the specific characteristics of rural areas require specific strategies, resource allocation, and indicators which fit their local conditions. This planning process requires comparison with other rural areas. This demonstration study aimed to describe and compare specialized rural adult mental health services in Australia, Norway, and Spain; and to demonstrate the readiness of the healthcare ecosystem approach and the DESDE-LTC mapping tool (Description and Evaluation of Services and Directories of Long Term Care) for comparing rural care between countries and across areas.

METHODS

The study described and classified the services using the DESDE-LTC. The analyses included context analysis, care availability, placement capacity, balance of care, and diversity of care. Additionally, readiness (Technology Readiness Levels - TRL) and impact analyses (Adoption Impact Ladder - AIL) were also assessed by two independent raters.

RESULTS

The findings demonstrated the usability of the healthcare ecosystem approach and the DESDE-LTC to map and identify differences and similarities in the pattern of care of highly divergent rural areas. Day care had a greater weight in the European pattern of care, while it was replaced by social outpatient care in Australian areas. In contrast, care coordination was more common in Australia, pointing to a more fragmented system that requires navigation services. The share between hospital and community residential care showed no differences between the two regions, but there were differences between catchment areas. The healthcare ecosystem approach showed a TRL 8 (the tool has been demonstrated in a real-world environment and it is ready for release and general use) and an AIL of 5 (the target public agencies provided resources for its completion). Two experts evaluated the readiness of the use of DESDE-LTC in their respective regional studies. All of them were classified using the TRL.

DISCUSSION

In conclusion, this study strongly supports gathering data on the provision of care in rural areas using standardized methods to inform rural service planning. It provides information on context and service availability, capacity and balance of care that may improve, directly or through subsequent analyses, the management and planning of services in rural areas.

Flexible Assertive Community Treatment in Rural and Remote Areas: A Qualitative Study of the Challenges and Adaptations of the Model

Background

Flexible assertive community treatment (FACT) is an innovative model for providing long-term treatment to people with severe mental illness. The model was developed in the Netherlands but is now used in other countries, including Norway, which has a geography different from the Netherlands, with many rural and remote areas. Implementation of innovations is context dependent. The FACT model's potential in rural and remote areas has not been studied. Therefore, we aimed to gain knowledge regarding the challenges and modifications of the model in rural and remote contexts and discuss how they can affect the model's potential in such areas. This knowledge can improve the understanding of how FACT or similar services can be adapted to function most optimally in such conditions. We sought to address the following questions: Which elements of the FACT model do team leaders of the rural FACT teams find particularly challenging due to the context, and what modifications have the teams made to the model?

Methods

Digital interviews were conducted with five team leaders from five rural FACT teams in different parts of Norway. They were selected using purposive sampling to include team leaders from some of the most rural teams in Norway. The interviews were analyzed using thematic text analysis.

Results

The following three themes described elements of the FACT model that were experienced particularly challenging in the rural and remote context: multidisciplinary shared caseload approach, intensive outreach and crisis management. The following eight themes described the modifications that the teams had made to the model: intermunicipal collaboration, context-adaptive planning, delegation of tasks to municipal services, part-time employment, different geographical locations of staff, use of digital tools, fewer FACT board meetings, and reduced caseload.

Conclusions

Rural and remote contexts challenge the FACT model's potential. However, modifications can be made, some of which can be considered innovative modifications that can increase the model's potential in such areas, while others might move the teams further away from the model.

Standardised description of health and social care: A systematic review of use of the ESMS/DESDE (European Service Mapping Schedule/Description and Evaluation of Services and DirectoriEs)

BACKGROUND

Evidence-informed planning and interpretation of research results both require standardised description of local care delivery context. Such context analysis descriptions should be comparable across regions and countries to allow benchmarking and organizational learning, and for research findings to be interpreted in context. The European Service Mapping Schedule (ESMS) is a classification of adult mental health services that was later adapted for the assessment of health and social systems research (Description and Evaluation of Services and DirectoriEs - DESDE). The aim of the study was to review the diffusion and use of the ESMS/DESDE system in health and social care and its impact in health policy and decision-making.

METHOD

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (1997-2018).

RESULTS

Out of 155 papers mentioning ESMS/DESDE, 71 have used it for service research and planning. The classification has been translated into eight languages and has been used by seven international research networks. Since 2000, it has originated 11 instruments for health system research with extensive analysis of their metric properties. The ESMS/DESDE coding system has been used in 585 catchment areas in 34 countries for description of services delivery at local, regional and national levels.

CONCLUSIONS

The ESMS/DESDE system provides a common terminology, a classification of care services, and a set of tools allowing a variety of aims to be addressed in healthcare and health systems research. It facilitates comparisons across and within countries for evidence-informed planning.

Standard comparison of local mental health care systems in eight European countries

AIMS

There is a need of more quantitative standardised data to compare local Mental Health Systems (MHSs) across international jurisdictions. Problems related to terminological variability and commensurability in the evaluation of services hamper like-with-like comparisons and hinder the development of work in this area. This study was aimed to provide standard assessment and comparison of MHS in selected local areas in Europe, contributing to a better understanding of MHS and related allocation of resources at local level and to lessen the scarcity in standard service comparison in Europe. This study is part of the Seventh Framework programme REFINEMENT (Research on Financing Systems' Effect on the Quality of Mental Health Care in Europe) project.

METHODS

A total of eight study areas from European countries with different systems of care (Austria, England, Finland, France, Italy, Norway, Romania, Spain) were analysed using a standard open-access classification system (Description and Evaluation of Services for Long Term Care in Europe, DESDE-LTC). All publicly funded services universally accessible to adults (≥18 years) with a psychiatric disorder were coded. Care availability, diversity and capacity were compared across these eight local MHS.

RESULTS

The comparison of MHS revealed more community-oriented delivery systems in the areas of England (Hampshire) and Southern European countries (Verona - Italy and Girona - Spain). Community-oriented systems with a higher proportion of hospital care were identified in Austria (Industrieviertel) and Scandinavian countries (Sør-Trøndelag in Norway and Helsinki-Uusimaa in Finland), while Loiret (France) was considered as a predominantly hospital-based system. The MHS in Suceava (Romania) was still in transition to community care.

CONCLUSIONS

There is a significant variation in care availability and capacity across MHS of local areas in Europe. This information is relevant for understanding the process of implementation of community-oriented mental health care in local areas. Standard comparison of care provision in local areas is important for context analysis and policy planning.

A Comparison of Mental Health Care Systems in Northern and Southern Europe: A Service Mapping Study

Mental health services (MHS) have gone through vast changes during the last decades, shifting from hospital to community-based care. Developing the optimal balance and use of resources requires standard comparisons of mental health care systems across countries. This study aimed to compare the structure, personnel resource allocation, and the productivity of the MHS in two benchmark health districts in a Nordic welfare state and a southern European, family-centered country. The study is part of the REFINEMENT (Research on Financing Systems' Effect on the Quality of Mental Health Care) project. The study areas were the Helsinki and Uusimaa region in Finland and the Girona region in Spain. The MHS were mapped by using the DESDE-LTC (Description and Evaluation of Services and Directories for Long Term Care) tool. There were 6.7 times more personnel resources in the MHS in Helsinki and Uusimaa than in Girona. The resource allocation was more residential-service-oriented in Helsinki and Uusimaa. The difference in mental health personnel resources is not explained by the respective differences in the need for MHS among the population. It is important to make a standard comparison of the MHS for supporting policymaking and to ensure equal access to care across European countries.

Identifying Local and Centralized Mental Health Services-The Development of a New Categorizing Variable

The challenges of mental health and substance abuse services (MHS) require shifting of the balance of resources from institutional care to community care. In order to track progress, an instrument that can describe these attributes of MHS is needed. We created a coding variable in the European Service Mapping Schedule-Revised (ESMS-R) mapping tool using a modified Delphi panel that classified MHS into centralized, local services with gatekeeping and local services without gatekeeping. For feasibility and validity, we tested the variable on a dataset comprising MHS in Southern Finland, covering a population of 2.3 million people. There were differences in the characteristics of services between our study regions. In our data, 41% were classified as centralized, 37% as local without gatekeeping and 22% as local services with gatekeeping. The proportion of resources allocated to local services varied from 20% to 43%. Reclassifying ESMS-R is an easy way to compare the important local vs. centralized balance of MHS systems globally, where such data exists. Further international studies comparing systems and validating this approach are needed.

Effect of stage, comorbidities and treatment on survival among cancer patients with or without mental illness

BackgroundEarlier research suggests poorer outcome of cancer care among people with severe mental illness (SMI).AimsTo assess the effect of stage at presentation, comorbidities and treatment on differences in survival among cancer patients with and without a history of SMI in Finland.MethodThe total population with a first cancer diagnosis in 1990-2013 was drawn from the Finnish Cancer Registry. Hospital admissions because of SMI and deaths were obtained from administrative registers. We calculated Kaplan-Meier estimates and Cox regression models to examine survival differences.ResultsWe found excess mortality in people with a history of psychotic and substance use disorders. Cancer stage and comorbidity did not explain mortality differences. Controlling for cancer treatment decreased the differences. The mortality gap between patients with psychosis and cancer patients without SMI increased over time.ConclusionsIntegrated medical and psychiatric care is needed to improve outcomes of cancer care among patients with SMI.

Regional Correlates of Psychiatric Inpatient Treatment

Current reforms of mental health and substance abuse services (MHS) emphasize community-based care and the downsizing of psychiatric hospitals. Reductions in acute and semi-acute hospital beds are achieved through shortened stays or by avoiding hospitalization. Understanding the factors that drive the current inpatient treatment provision is essential. We investigated how the MHS service structure (diversity of services and balance of personnel resources) and indicators of service need (mental health index, education, single household, and alcohol sales) correlated with acute and semi-acute inpatient treatment provision. The European Service Mapping Schedule-Revised (ESMS-R) tool was used to classify the adult MHS structure in southern Finland (population 1.8 million, 18+ years). The diversity of MHS in terms of range of outpatient and day care services or the overall personnel resourcing in inpatient or outpatient services was not associated with the inpatient treatment provision. In the univariate analyses, sold alcohol was associated with the inpatient treatment provision, while in the multivariate modeling, only a general index for mental health needs was associated with greater hospitalization. In the dehospitalization process, direct resource re-allocation and substituting of inpatient treatment with outpatient care per se is likely insufficient, since inpatient treatment is linked to contextual factors in the population and the health care system. Mental health services reforms require both strategic planning of service system as a whole and detailed understanding of effects of societal components.