Integrated Health and Social Services for People With Chronic Mental Health Problems: People Are More Important Than Processes. Insights From a Multiple Case Study in Swedish Psychiatry.

Three mental health organizations, one merged with, one formally cooperating with, and one without formal links to social services were analyzed through the experience of staff, patients and relatives in order to elucidate what approaches best promoted service coordination. Seventeen staff and eight patients or relatives, recruited from the three organizations, participated in semi-structured interviews, guided by pre-selected categories derived from previous research about coordination and care processes. Directed content analysis was used to identify and categorize meaning units. Both staff and patients raised the same concerns. Organized collaboration between psychiatric care and social services addressed only some of patients' challenges. More important was patient access to financial and social assistance. The organizational arrangements were not referred to, whereas case management was seen as crucial. In many instances relatives have to act as case managers. Service integration in mental health has to include, in addition to social services, other authorities like social insurance and employment agencies. A case manager knowledgeable about all welfare services is best positioned to promote that "extended integration". Relatives often have to take this responsibility to support this fragile group of patients. This observed importance of case management is supported by previous research in mental health and primary care. The role of relatives should be acknowledged and supported by those services.

Coordination pays off: a comparison of two models for organizing hip fracture care, outcomes and costs.

BACKGROUND AND PURPOSE: With the "graying" of the population, hip fractures place an increasing burden on health systems and call for efficient forms of care. The aim was to compare two models of organizing hip fracture care at one university hospital working at two sites. The differences in organization were coordinated care provided in one of the sites and traditional care, divided between different institutions, in the other. MATERIAL AND METHODS: The study was conducted at a Swedish university hospital and included all 503 hip fracture patients, admitted during the 1-year period of February 2009 through January 2010. Patient gender, age, type of fracture, admission and discharge dates were documented. The patients were surveyed of their health-related quality of life at the time of admission and at 4 and 12 months after discharge. The costs for the inpatient care episode were estimated using three costing methods. RESULTS: The coordinated care model resulted in a shorter hospital stay and consistently lower costs. There was no difference between patient-reported quality of life. INTERPRETATION: The care of hip fracture patients coordinated by a geriatric ward throughout the whole care episode is more cost-efficient than uncoordinated where patients are transferred to other institutions for rehabilitation.

Case study of how successful coordination was achieved between a mental health and social care service in Sweden.

This paper summarises the findings from an empirical longitudinal study of a health and social care consortium for people with mental health problems in one area in Stockholm. The aim was to describe the formation and structure of coordination within the consortium, and to assess the intermediate impact on care processes and client outcomes. A multiple-method case study design, theoretically informed by the Pettigrew and Whipp model of strategic change (1993) was applied. Data was gathered from interviews with informants from different organisations at different times in the development of the consortium, and from administrative documents, plans and service statistics showing some of the intermediate changes and client outcomes. The findings revealed activities and factors both helping and hindering the formation of coordination arrangements. One of the most significant hindering factors was the central county purchasing organisation focusing more on volume and costs, with payments for specific units and services, and with less emphasis on quality of the services. Few studies have described implementation of changes to improve coordination with reference to context over a long period of time, as well as assessing different results. This study contributes to knowledge about improved methods for this type of research, as well as knowledge about developing coordination between public health and welfare services. One lesson for the current policy is that, where full structural integration is not possible, then client-level coordination roles in each sector are useful to connect sector services for shared clients.

Coordination in networks for improved mental health service.

INTRODUCTION: Well-organised clinical cooperation between health and social services has been difficult to achieve in Sweden as in other countries. This paper presents an empirical study of a mental health coordination network in one area in Stockholm. The aim was to describe the development and nature of coordination within a mental health and social care consortium and to assess the impact on care processes and client outcomes. METHOD: Data was gathered through interviews with 'joint coordinators' (n=6) from three rehabilitation units. The interviews focused on coordination activities aimed at supporting the clients' needs and investigated how the joint coordinators acted according to the consortium's holistic approach. Data on The Camberwell Assessment of Need (CAN-S) showing clients' satisfaction was used to assess on set of outcomes (n=1262). RESULTS: The findings revealed different coordination activities and factors both helping and hindering the network coordination activities. One helpful factor was the history of local and personal informal cooperation and shared responsibilities evident. Unclear roles and routines hindered cooperation. CONCLUSIONS: This contribution is an empirical example and a model for organisations establishing structures for network coordination. One lesson for current policy about integrated health care is to adapt and implement joint coordinators where full structural integration is not possible. Another lesson, based on the idea of patient quality by coordinated care, is specifically to adapt the work of the local addiction treatment and preventive team (ATPT)-an independent special team in the psychiatric outpatient care that provides consultation and support to the units and serves psychotic clients with addictive problems.

Lean thinking in healthcare: a realist review of the literature.

OBJECTIVE: To understand how lean thinking has been put into practice in healthcare and how it has worked. DESIGN: A realist literature review. Data sources The authors systematically searched for articles in PubMed, Web of Science and Business Source Premier (January 1998 to February 2008) and then added articles through a snowball approach. REVIEW METHODS: The authors included empirical studies of lean thinking applications in healthcare and excluded those articles that did not influence patient care, or reported hybrid approaches. The authors conducted a thematic analysis based on data collected using an original abstraction form. Based on this, they articulated interactions between context, lean interventions, mechanisms and outcomes. RESULTS: The authors reviewed 33 articles and found a wide range of lean applications. The articles describe initial implementation stages and emphasise technical aspects. All articles report positive results. The authors found common contextual aspects which interact with different components of the lean interventions and trigger four different change mechanisms: understand processes to generate shared understanding; organise and design for effectiveness and efficiency; improve error detection to increase awareness and process reliability; and collaborate to systematically solve problems to enhance continual improvement. CONCLUSIONS: Lean thinking has been applied successfully in a wide variety of healthcare settings. While lean theory emphasises a holistic view, most cases report narrower technical applications with limited organisational reach. To better realise the potential benefits, healthcare organisations need to directly involve senior management, work across functional divides, pursue value creation for patients and other customers, and nurture a long-term view of continual improvement.

An integrated health and social care organisation in Sweden: creation and structure of a unique local public health and social care system.

Research and citizens have noted failures in coordinating health and social services and professionals, and the need to address this issue to realize benefits from increasing specialisation. Different methods have been proposed and one has been structural integration of separate services within one organisation. This paper reports an empirical longitudinal study of the development of an integrated health and social care organisation in Sweden combining service provision, purchasing and political governance for a defined population. The study found a combination of influences contributed to the development of this new organisation. The initial structural macro-integration facilitated, but did not of itself result in better clinical care coordination. Other actions were needed to modify the specialised systems and cultures which the organisation inherited. The study design was not able to establish with any degree of certainty whether better patient and cost outcomes resulted, but it did find structural and process changes which make improved outcomes likely. The study concludes that coordinated actions at different levels and of different types were needed to achieve care coordination for patients and that a phased approach was necessary where management capacity and outside expertise are limited.