Evaluation of new flexible and integrative psychiatric treatment models in Germany- assessment and preliminary validation of specific program components.

BACKGROUND: Flexible and integrative treatment (FIT) models are rather novel in German mental health care. This study aimed at identifying and evaluating empirically based, practicable, and quantifiable program components that describe the specific treatment structures and processes of German FIT models. METHODS: A multi-step, iterative research process, based on Grounded Theory Methodology (GTM), was used to identify and operationalise components. A complex algorithm and expert-interviews were applied to quantify the relative weight of each component and to develop a sum score. Face and content validity were examined and internal consistency was tested by Cronbach's α coefficient. RESULTS: Ten of eleven FIT components could be operationalised, quantified and united in the total score. All operationalised components showed sufficient face and content validity and eight components had a good reliability. CONCLUSIONS: The components are a first step in the process of operationally defining German FIT models. They considerably overlap with various critical ingredients of international FIT models and may serve as a theoretical basis for constructing fidelity tools and research guides to enable process and outcome evaluation of German FIT models.

Changes in German Mental Health Care by Implementing a Global Treatment Budget-A Mixed-Method Process Evaluation Study.

BACKGROUND: Internationally, there is a broad spectrum of outreach and integrative care models, whereas in Germany acute psychiatric treatment is still mostly provided in inpatient settings. To overcome this, a new legal framework (§64b Social Code V) has been introduced, promoting "Flexible and Integrative Treatment" Models (FIT64b), based on a "Global Treatment Budget" (GTB) financing approach. 23 hospitals have implemented the framework according to local needs and concepts. Prior research has already identified specific components of FIT64b. Based on this, our paper aims to examine the implementation process and underpinning change mechanisms of GTB-based FIT64b models from a staff, service user and caregiver perspective. METHOD: 31 focus groups and 15 semi-structured interviews were conducted with hospital staff (n = 138), service users (n = 63), and caregivers (n = 35) in 10 psychiatric hospitals implementing FIT64b. Using qualitative analysis, we identified 5 core themes describing the implementation process, which were theoretically modeled into a logical diagram. The core mechanisms of change were thus identified across themes. Additional structural and semi-quantitative performance data was collected from all study departments. RESULTS: The qualitative analysis showed that the shift from a daily- and performance-based payment to a lump-sum GTB and the shift of resources from in- to outpatient settings were of crucial importance for the process of change. Saved budget shares could be reinvested to integrate in-, out-, and day-patient units and to set up outreach home care. Clinicians reported feeling relieved by the increase of treatment options. They also emphasized a stronger relationship with and a better understanding of service users and a simplification of bureaucracy. Finally, service users and caregivers experienced higher need-adaptedness of treatment, a feeling of deeper understanding and safety, and the possibility to maintain everyday life during treatment. Finally, two FIT64b implementation prototypes were classified according to the semi-quantitative performance data. CONCLUSION: Based on the results, we developed 3 core mechanisms of change of FIT64b models: (1) Need-adaptedness and flexibility; (2) Continuity of care; (3) Maintaining everyday life. Our findings outline and emphasize the potential a GTB approach may have for improving psychiatric hospital services.

Evaluation of Flexible and Integrative Psychiatric Treatment Models in Germany-A Mixed-Method Patient and Staff-Oriented Exploratory Study.

Contrary to the practice in some countries, access to flexible and integrated forms of psychiatric care (FIT models) is limited in Germany. Several legislations have been introduced to improve this situation, notably the recent §64b (flexible and integrative treatment model; FIT64b) of the German Social Code, which allows for a capitation-based accounting of fees for services. The aim of this study was to explore the effects of FIT64b implementation on various stakeholders (patients, informal caregivers and staff) in 12 psychiatric hospital departments across Germany. Structural as well as quantitative and qualitative data are included, with integration of different methodological approaches. In all departments, the implementation of the new accounting system resulted into a relatively stable set of structural and processual changes where rigid forms of mainly inpatient care shifted to more flexible and integrated types of outpatient and outreach treatments. These changes were more likely to be perceived by patients and staff, and likewise received better evaluations, in those departments showing higher level or longer duration of implementation. Patients' evaluations, furthermore, were largely influenced by the advent of continuous forms of care, better accessibility, and by their degree of autonomy in steering of their services.