Providing Integrated Mental Health Services: A Policy and Management Perspective

Abstract

Objective: To review the challenge of providing integrated mental health services from a policy and health management perspective.

Conclusions: The provision of integrated mental health services involving specialist mental health services, general practitioners, psychiatric disability and rehabilitation services and public community health services is a major challenge in the Australian health care context and is increasingly an expectation of the community. Government, Divisions of General Practice and public community health policy and many Government, State and local initiatives have attempted to address this challenge. However, much remains to be done, including culture change within services and professions and the development of technology to support integrated service provision.

Keywords

government policy integration mental health partnerships

Providing integrated health care, particularly for those with chronic illness, has been a major challenge and ambition of developed countries for many years.1–3 The driving forces for integrating care fall into three categories: concern about the quality and continuity of services (including the target of earlier intervention), concern about the cost of health (need to minimize expensive interventions such as hospitalization and reduce duplication of servicing), and community demand for higher standards and better coordination. It has long been recognized that Australian funding and service delivery models for primary health and community care are fragmented and are often disconnected from acute and continuing care services, and that these, in turn, are often disconnected from one another.[4], [5] In the area of mental health, private psychiatrists provide a significant contribution to the care of those with a wide range of illnesses, but they are unavailable to many because of their uneven distribution across the community or because consumers cannot afford their services and because they often do not or cannot work collaboratively with the public mental health sector, for a variety of reasons. Non-government organizations such as Psychiatric Disability and Rehabilitation services also provide significant services for those with a wide range of mental illnesses. Public mental health services have traditionally been isolated from other health services. Although this is becoming less the case, a new threat is risking progress because they struggle to cope with increasing demand bynarrowing their focus on those with serious mental illness. People with less severe illnesses (the so-called high prevalence disorders, including substance use disorders) either receive care from general practitioners (GPs), community drug treatment services, community health counsellors or other private providers, such as private psychologists, or receive no care at all.

The above-described baffling array of service providers and the general lack of coordination between them present particular challenges for mental health consumers and their carers who often find difficulty navigating these systems. Their care and social needs frequently span a wide range from housing, employment and general health to acute mental health care and rehabilitation services, and many suffer from chronic illness. In the present paper, we examine the challenge of integrating the provision of mental health services, including the formation of partnerships and strategic alliances, from two perspectives. First, we consider the national policy perspective and examine some initiatives aimed at integrating care. Second, we examine the issue from a management perspective and explore concepts from the management literature, which may be useful in conceptualizing the challenges of integration and collaboration.

POLICY PERSPECTIVE

National Mental Health Policy

The issues of integration and coordination have been of concern within the Australian health system for several years. The first of the National Health Strategy Issues papers, The Australian Health Jigsaw,[6] was devoted to this matter and was followed by The Future of General Prac-tice,[7] which called for general practice to play a more integrated role in the broader health system.

The Second National Mental Health Plan identified the development of partnerships in service reform and delivery as one of the three priority areas for the period, 1998– 2003, and noted that key strategic alliances need to be formed with GPs, private psychiatrists and the wider health sector.[8] This was consistent with the broadening of the focus from people with psychotic disorders in the first plan to include people with depressive disorders and health promotion. However, in their mid-term review of the Second National Mental Health Plan, Betts and Thornicroft, while finding that the provisions of the plan to encourage multiple partnerships were beginning to bear fruit, were particularly critical of the administrative separation of mental health and substance abuse services at Commonwealth and State and Territory levels; Betts and Thornicroft suggested this ‘fosters a degree ofoperational division that acts against the interests of those with dual diagnosis’ (p. 17).[9] In the final review of the Second National Mental Health Plan, it was concluded that recent initiatives (including the Mental Health Integration Projects) must be sustained and more widely implemented to ensure partnerships between primary care and specialist mental health care (both public and private).[10] The Third National Mental Health Plan (2003–2008) continued the commitment to increased integration between private and public mental health services (outcome 21) and improved coordination between the mental health sector and other areas of health (outcome 22).[11]

Public mental health service–private psychiatrist collaboration

In 1997, the final report ofthe evaluation of the National Mental Health Strategy concluded that ‘Minimum communication between local public mental health services and private psychiatrists was seen to contribute to poor outcomes for consumers’ (p. 18).[12] The Mental Health Integration Projects (MHIPs) were developed to create a more flexible, integrated framework for the delivery of mental health services.[13] One of the projects, the St Vincent's Mental Health service (Melbourne) and the Melbourne Clinic joint initiative, focused on integrating private psychiatrist services and public sector mental health services. One of the most significant findings was that the degree ofcultural change required for successful partnership between public services and private psychiatrists, at least in a large city context, presents a major challenge to progressing collaboration.[14] Interestingly, as this project progressed, it became clear that in order to be effective, partnerships needed to be expanded beyond the private and public sector to include primary care, which includes general practice, public sector community health services and other local government and non-government service providers. To date, three largescale MHIPs have been externally evaluated as effective. These evaluations have demonstrated that there are considerable barriers to providing integrated mental health care, that improving integration is very difficult, that improved integration can only occur in the context of systems and cultural change, that one model of collaboration does not fitall circumstances, and that leadership from within the psychiatry profession is critical to drive culture change within the profession.[15]

Public mental health service–primary care collaboration

The final report of the evaluation of the National Mental Health Strategy (1997) referred to above described the relationships between GPs and specialist mental health services as relatively underdeveloped and stated that considerable research had shown that the burden of responding to the majority of mental health need in the community was carried by GPs.[12] In 1996–1997, a strategic alliance between the Royal Australian College of GPs and the Royal Australian and New Zealand College of Psychiatrists led to a report entitled ‘Primary Care Psychiatry: The Last Frontier’. It confirmed the key role of GPs in Primary Mental Health Care and acknowledged that GPs needed to be assisted by increased availability of specialist psychiatry services.[16] An important national initiative with potential to integrate efforts to provide mental health services has been the establishment of the National Primary Mental Health Care Network in 1999, by the Commonwealth Government. This aims to support GPs providing mental health care by facilitating their access to education in mental health and the improvement of linkages with specialist mental health services in the public, private and non-government sec-tors.[17] The majority of Divisions of General Practice have developed and implemented mental health projects that focus on inter-sector partnerships. Also, in 1999, a suite of Enhanced Primary Care Items was introduced under the Medicare Benefits Schedule which meant that GPs could be remunerated for non-consumer contact time spent discussing and planning care with other health professionals. This was followed by the Better Outcomes in Mental Health Care Initiative to provide financial incentives when, in 2001, the Commonwealth budget provided $$A120.4m over 4years to improve the quality of care provided through general practice to Australians with a mental health illness.[18] This initiative has five major components: incentive payments for GPs to reward and encourage effective management of mental health problems, education and training for GPs, Medicare Benefits Schedule Items for GP focused psychological strategies, access to allied health services for GPs and a Medicare Benefits Schedule Item for psychiatrist case conferencing.

Of course, many excellent examples of shared care and good relationships exist throughout the country.[19], [20] However, some public mental health services are experiencing so much demand in a context of relative underfunding, that resource–intensive collaboration with GPs is an unrealistic expectation. Incentives such as the Commonwealth initiatives alone will not ensure collaboration between GPs and the public sector while GPs experience difficulty with access for any of their patients, except those who are psychotic or suicidal, and as long as GPs have a sense of being abandoned with seriously ill patients.21–23

In Victoria, each Area Mental Health Service has been funded to establish a Primary Mental Health Team and Early Intervention Service (PMHT&EI). Each service has developed a different staffing mix but typically the budget allows for several sessions of a psychiatrist and four other workers whose role is to support primary care, including GPs and Community Health Services in treating people with high prevalence disorders and identifying serious illness as early as possible.[24] An innovative integrated partnership between the GP Division Better Outcomes in Mental Health Care and the PMHT&EI has been developed in Northeast Victoria that combines Commonwealth and State funding to form an ‘Integrated Primary Mental Health Service (information available at http://www.health.gov.au/internet/wcms/publishing.nsf/Content/mentalhealth-boimhc-abstracts-vic__northeastvictorian.htm). An independent evaluation of this initiative has been very promising with high consumer and GP satisfaction and a 30% reduction in referrals to the public mental health service locally (pers. comm.).

Little has been written in Australia about the need for integration and collaboration between specialist mental health services and the non-GP primary care sector, although many references are made to this in some of the documents cited above. The Department of Human Services in Victoria is making considerable progress in examining the role of Community Health Counselling services in relation to the management of high prevalence disorders and expenditure on counselling through the Community Health Program in 2001–2002 was approximately $$A15.5m.[25] In addition, a paper has been issued to the sector inviting specialist mental health and early intervention teams, community health services and GPs to form partnerships in the provision of mental health treatment in primary care settings in Vic-toria.[26] Finally, significant progress has been made in Victoria in implementing Service Coordination between Community Health, Drug Treatment Services, Aged Care Services and Psychiatric Disability and Rehabilitation Services, in part, by the mandated use of a set of standardized assessment and care–coordination templates that are supported by software versions of the tools and E-tool templates. This initiative is auspiced by the Primary Care Partnerships (PCPs) strategy[27] and an independent evaluation of this strategy is now available.[28] The Mental Health Branch in Victoria is currently exploring how Mental Health Services will fit into this coordinated system within the next 2 years.

Although it is recognized that other States and Territories are making efforts to grapple with the challenge of providing integrated care, the Victorian developments have been elaborated here so as to emphasize that much progress is being made outside the direct area of specialist mental health services, which mental health clinician-managers need to be aware of, and align with their endeavours.

THE HEALTH MANAGEMENT PERSPECTIVE ON INTEGRATION AND COLLABORATION

Structure

There are many structural and funding arrangement barriers to delivering integrated care. For example, community-based health services have many different funding streams (usually accompanied by separate data collection and reporting arrangements), which discourage the formation of integrated care systems from a management perspective. It is repeatedly argued in the literature that agreed National policies and better alignment between Commonwealth and State funding would support more progress by organizations in delivering a more integrated health-care system.[4] It should be clear that while policy development at a State or Government level is important to drive structural change, and while structural changes, particularly to State and Federal Government funding arrangements, may be necessary, policy and structural change alone will not achieve integrated care.

Leutz defined integration as the search to connect the health-care system with other human service systems (e.g. long-term care, education, vocational and housing services) in order to improve outcomes (clinical, satisfaction and efficiency). The term ‘integration’ as defined by Leutz can mean anything from linkages, through coordination to full integration of services clinically and administratively.[29] In the past, organizations and systems theory has emphasized the importance of maintaining boundaries to the survival and integrity of organizations.[30] However, the downside of boundary maintenance is that it often prohibits the appropriate flow of consumers and staff across the boundaries, impedes access for consumers to comprehensive services and limits interagency collaboration and treatment planning.

Structures refer to the formal relationship between interdependent organizations and between the interdependent parts within an organization.[31] Structure facilitates or inhibits the necessary exchange of information so that activities can be coordinated: it does not, of itself, perform that function. Structure is also important symbolically as it reflects the organization's vision and strategy. Vertical integration involves a hierarchical organization, which offers the majority ofservices to a specific consumergroup. Horizontal integration involves the aggregation of complementary organizations in the same business. Virtual integration is structured around a set of service providers who will coordinate their actions so as to offer a diversified, continuous service to the consumers.

All of Australia's major private hospital groups have emerged through horizontal integration (e.g. Ramsay Healthcare and Healthscope). In the late 1990s, a number ofprivate organizations sought to integrate vertically (e.g. Maine Health that has acquired general practices, pathology and imaging services and some private hospital and daily hospital facilities). In Victoria, 60% of Community Health Services are part of vertically integrated health services, and most of the ‘stand-alone’ Community Health Services’ ‘catchments’ reflect previous horizontal integrations with other organizations providing community-based care and treatment.

Among the intended benefits of vertical and horizontal integration are economies of scale, reduced duplication of services and better coordination of services. However, the limited empirical evidence, at least in relation to vertically integrated organizations, suggest that equal or greater inefficiencies and organizational problems may be created.[32] Accordingly, some argue that virtual integration as a service organization structure would be better suited to the complexity of health systems, allowing greater flexibility to adapt to diversified consumer needs (although most authors agree that there is no ideal service integration model and that models must be shaped to fit context, culture and local needs).[33] Of course, virtual organizations will have problems associated with their loose structure. For example, virtual organizations will have difficulty fostering quality improvement strategies because leadership and organizational culture will be difficult to implement within them.[34]

Process

There is a considerable body of literature available to support interagency collaboration and partnership, particularly from the UK where an extensive, multipronged approach has been taken by government to build a system of integrated care.35–37 The Nuffield Centre Final Report on Interagency Collaboration elaborates principles of facilitating collaboration: a shared vision, clarifying roles and responsibilities, ensuring appropriate incentives and rewards and monitoring achievements, and providing feedback to support accountability.[38]

In Australia, Jackson and de Jong have described in detail their three ‘C's’ model of health-care integration.[39] These are: communication and access, commitment and incentives, and the need to establish an integration culture with associated values and teamwork.

Management of partnerships in virtually integrated systems will entail confronting dilemmas that are inherent to getting loosely connected organizations to work together in ways that permit autonomy, experimentation and flexibility.[40] The challenge will be to manage divergent goals and interests that are important to key stakeholders, to balance rival perspectives and to assure flexible leadership in managing ambiguities and multiple directions. This will mean the promotion of tightly held values with staff that supports staff learning and empowerment in a more loosely structured environment than organizations with impermeable boundaries are used to. Governance and accountability will be difficult to organize but still require critical attention.[33]

The technology and Internet revolution, which is sweeping society but has been harnessed to a limited extent only by health-care systems, will be of increasing importance. Coordinating patient care technology, integrated information systems that allow controlled sharing of information between agencies and the electronic medical record will form the linchpin of clinical integration between agencies.[41] It is being increasingly recognized that the practice of developing patient information systems that serve the data collection needs of Government or administration, rather than the needs of the clinicians who will use them and the consumer whose care they will support, simply leads to systems that are not used; their use is considered to be an encroachment on valuable clinician time and real possibilities for improved integration of patient care are missed.[42] In short, consumer-centred information systems are required and Governments will support this trend as it becomesclear that their ultimateneeds are best served by this approach.

OUTCOMES

As mentioned, there is mixed evidence about the outcomes ofintegration and groups in general industry, and the benefits in health care have only been demonstrated on the basis of a few studies whose findings are mostly inconclusive or negative.[33] This situation arises from the difficulty in evaluation where there are great differences in models, and variation in context and degree of success in fully implementing these models. Such findings suggest that it may be more appropriate, at least in the short-term, to focus research and evaluation efforts on integration strategies, the factors associated with their success in transforming health-care systems, changes in consumer access and patient satisfaction with services.

CONCLUSIONS

The community is becoming increasingly intolerant of such excuses offered for the inability of services to provide seamless integrated care as historically-based inflexible structures, the pervasive interests of different professions in maintaining their status within the health system, management complaints about difficulties associated with working constructively with other agencies which are not part of the parent organization, and difficulties associated with changing organizational culture. It is increasingly recognized that if we are to improve mental health services to the community, expansion of specialist services alone is not the answer. Some degree of integration and improved continuity with the primary care services that provide care to the majority of those with mental illnesses is essential. Although some remain critical of the extent to which Governments are supporting systems to change and provide more integrated care, much has been done and mental health leaders and managers can learn from work already underway in other areas of health, including public community health services. With committed leadership, organizations can gradually develop the capacity to work together collaboratively and productively across organizational boundaries by pursuing joint projects incrementally. Technological advances can be used to address consumer care needs across boundaries by reducing duplication of information gathering, and supporting interorganizational care and care planning. Mental health services have led the way in integrating community and inpatient care in health generally, but now face the challengeof going further in providing integratedcare in partnership with GPs, drug treatment services and community health.

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