Organizing mental health services: an evidence-based approach

Abstract

Background and Aims. Health policy makers and program developers seek evidence-based guidance on how to organize and finance mental health services. The Swedish Council on Technology Assessment in Health Care (SBU) commissioned a conceptual framework for thinking about health care services as a medical technology. The following framework was developed, citing empirical research from mental health services research as the case example. Framework. Historically, mental health services have focused on the organization and locus of care. Health care settings have been conceptualized as medical technologies, treatments in themselves. For example, the field speaks of an era of 'asylum treatment' and 'community care'. Hospitals and community mental health centers are viewed as treatments with indications and 'dosages', such as length of stay criteria. Assessment of mental health services often has focused on organizations and on administrative science.There are two principal perspectives for assessing the contribution of the organization of services on health. One perspective is derived from clinical services research, in which the focus is on the impact of organized treatments (and their most common settings) on health status of individuals. The other perspective is based in service systems research, in which the focus is on the impact of organizational strategies on intermediate service patterns, such as continuity of care or integration, as well as health status. Methods. Examples of empirical investigations from clinical services research and service systems research are presented to demonstrate potential sources of evidence to support specific decisions for organizing mental health services. Results. Evidence on organizing mental health services may be found in both types of services research. In clinical services research studies, service settings are viewed as treatments (e.g. 'partial hospitalization'), some treatments are always embedded in a service matrix (e.g. assertive community treatment), and, where some treatments are organizationally combined (e.g. 'integrated treatment' for co-occurring mental disorder and substance abuse), sometimes into a continuum of care. In service system research, integration of services and of the service system are the main focus of investigation. Studies focus on horizontal and vertical integration, primary care or specialty care and local mental health authorities-each of which may be conceptualized as a health care technology with a body of evidence assessing its effectiveness.

Impact on continuity of care of decentralized versus partly centralized mental health care in Northern Norway

“…The concept of continuity of care has therefore been suggested as a more testable proxy for clinical outcome [3]. It represents the uninterrupted treatment for individuals suffering from serious psychiatric disorders, and has long been a key concept in the evaluation of deinstitutionalized psychiatric care systems [4, 14–16]. We decided to use findings associated with the concept of continuity of care in the analysis.…”

“…Supporters of the concept of continuity of care point to the benefits of combined treatment [16], while critics emphasize the disruptiveness that may occur in recurrent transitions of patients [17] or even the fostering of dependency and a chronic sick role [18]. Despite these controversies, recent results suggest a positive relationship between continuity of care and important health outcomes for severely ill patients, such as quality of life, better community functioning, lower severity of symptoms, and greater service satisfaction [19, 20].…”

“…Systems integration may be considered as vertical or horizontal, depending on whether it takes place at various levels of government, among services, on the basis of geography (e.g. sector) or specialization [16]. In our study, the vertical integration perspective is possibly most relevant, due to the organization of Norwegian psychiatric services on the basis of geographically defined sectors.…”

Does Systems Integration Affect Continuity of Mental Health Care?

“…System Performance One indicator of system performance is the number of mechanisms implemented at the service or clinical level to facilitate integration (Devers et al, 1994;Hoge, Davidson, Griffith, Sledge, & Howenstine, 1994;Goldman et al, 2000;Lefkovitz, 2001, chap. 2).…”

“…At the services level, integration refers to implementation of interventions such as case management, that are designed to create continuity of care for individual clients without necessarily altering the systems in which the services are provided (Bachrach, 1993;Randolph et al, 2002). At the systems level, integration involves creating a network of organizations that provides a coordinated continuum of services to a defined population, and is held clinically and fiscally responsible for the health status of that population (Devers et al, 1994;Goldman, Thelander, & Westrin, 2000).…”