Promoting Integrated Care through a Global Treatment Budget

Introduction: Since 2003, as a means of enabling integrated care the German mental health care system has offered the innovative option of agreeing a Global Treatment Budget (GTB, also known as a regional psychiatric budget or innovative flexible and integrative forms of treatment FIT) with health insurers and regional care providers across sectors. Despite promoting legal frameworks and positive evidence on improving quality of patient care, this model has not spread widely. The aim of this study is to identify inhibiting and facilitating factors for the innovation diffusion. Theory and methods: We conducted expert interviews with 19 actors from nine German regions involved in GTBs, using a self-developed questionnaire based on Rogers’ theory on innovation diffusion extended by the innovation system approach. Interviews were analysed applying qualitative content analysis. Code categories were built deductively operationalising Rogers’ theory and inductively from the data generated. Results: Observability of the innovation was perceived as good, but trialability, reversibility, compatibility with regular care structures as low, and thus the perceived risks of adoption as high. Complexity up to implementation is high, caused by numerous individuals and stakeholder groups involved. Diffusion took place in environments of strong individuals with venturesomeness, opinion leadership, and informal networking. As favourable framework conditions the monopoly and non-profit position of hospitals in well-defined care regions were identified. Discussion and Conclusions: Diffusion of integrated care could be accelerated by dissolving the multi-actor constellation, changing the communication strategy, and adapting the legal framework.

I would now like to come back to the GTB. C1. What did you decide to do in the process so far and why? D) Adoption process D1. When did you start developing this care model; when did the first ideas emerge? (Initiator) How did you perceive the idea? D1. When did you first learn about the GTB model? From whom did the initiative come? (Imitator) How did you perceive the idea? D2. What aroused your interest? What motivated you at the beginning?
D3. How did you evaluate the model? What information did you use to make your decision to participate/not participate/wait? D4. How did you approach the model yourself? Can you tell us something about the first steps of realisation? D5. When did you install/contract the model? Or rather, when, and why did you decide not to adopt the model?

G) Communication process
G1. How is the communication between the actors in the decision-making process? How quickly is feedback on the success of the innovation given to the GTB user itself and to previous GTB non-adopters and potential regions joining the GTB? Does communication take place through formal or informal channels? G2. How extensively did you initially communicate the model and how did you expand the audience? H5. How is the communication with the outside world? What do outsiders need to know if they also want to introduce the GTB, and how can this be communicated? What is the communication between the actors in the decision-making process?
H6. What effort and risk are associated with the introduction?

Additional questions
B1. Let us imagine that you were allowed to shape psychiatric care in Germany according to your own wishes: Which guiding goals would you define? Which potential guiding goals do you consider problematic or undesirable? (justification) B2. Do you consider the ideas you have just mentioned to be practicable and realisable?
B3. Let's come back to your desired guiding objectives: Now this is a context in which you do not decide, act and act alone. With a view to other relevant groups of actors: Which values or perceptions of mental health care do you consider essential, which values and perceptions, e.g. of the other actors do you consider obstructive to the realisation of your guiding goals?
Closing the interview J1. With your current level of knowledge and experience, would you make the same decision again?
J2. What do you personally think should happen so that more hospitals implement this model?
J3. Is there anything else that you think is important that we haven't talked about yet? What else would you like to tell us about the GTB?
Suppl. table 2: Main code categories and subcategories. Main code categories and subcategories marked with ® were operationalised from Rogers' diffusion of innovation model, subcategories marked with * were added inductively from the data generated.

Early adopter
The first region implemented the GTB to practice integrated care shortly after the pilot region. The rural-structured district has one inpatient service provider under municipal sponsorship. The GTB-contract was concluded with the state association of all SHIs in accordance with the law at that time. The community-based psychiatric care is dedicated to a social psychiatric approach and takes place in basically open treatment areas, both outpatient, day-clinic and inpatient mixed and in home treatment. With detailed knowledge of the care-relevant and contractual design options of a GTB from the pilot neighbourhood, the management of the hospital approached the payers for discussions to join the model itself 2 years later. The GTB was extended in each case under applicable legal conditions. The inpatient area was halved in favour of a strong expansion of integrated day-clinical and outpatient structures.
The second region nearby is a rural county with urban parts. The only multi-site inpatient psychiatric provider is non-profit and established a GTB as the first successor to the pilot. The contract was with the state association of all SHI. The number of beds was already low under regular care and was hardly reduced under GTB conditions, but day-clinic care was significantly expanded and integrated with home treatment. The model was extended in each case under applicable legal conditions.

Late adopter
In the urban region, the hospital is the only psychiatric provider, and non-profit under church sponsorship. The holistic (psychiatric, somatic, social) and community-integrated care principle includes inpatient, day-clinical and outpatient care. The GTB started about 10 years after the early adopters and was concluded with all SHIs. Inpatient treatment days have been reduced somewhat since then.
In the metropolitan region, mandatory psychiatric care is provided by several hospitals (private, non-profit, and municipal), each for a sub-region. The GTB was agreed between several hospitals of the municipal hospital group and one large German SHI and covers urban hotspot regions. In addition to inpatient, day-clinical and outpatient care, home treatment was integrated as a new service. Inpatient treatment days could be reduced for the insured. The integrated mental health care model could better reach the difficult-to-treat patients.

Failed adopter
Both urban regions with a rural setting are served by a non-profit clinic under municipal sponsorship.
With the knowledge of concrete preceding integrated care models (selectively and temporarily contracted with single SHIs) through active gathering of information, the hospital of the first region, interested in the GTB, worked on a concept to approach the contract partners with it. Over several years, the concepts were presented to the payers and intensively negotiated. Nevertheless, a contract was rejected by the payers for various reasons. No attempt was started to implement the GTB with only a selection of health insurers. During the negotiation period of about 10 years, the number of inpatient beds almost doubled, and the number of day-clinic places quadrupled, while the number of inhabitants increased only discreetly.
The second hospital offers inpatient, day-care and outpatient psychiatric treatment and is intricately linked with physicians in private practice and providers of psychosocial assistance as well as the public health service in the city. This region has received several awards for its integrated care model, which also includes work across social insurance codes. GTBnegotiations failed years later after administrative and legal obstacles in the establishment of a new management company to control care centrally were insurmountable.

Observer
The large rural region with some urban centres is served by a hospital with an inpatient centre, several day-clinics and community psychiatric sites. It is a public institution owned by the district. For many years, the hospital implemented an integrated care project with a large German SHI. Innovative components included peer support, trialogical work, and home treatment. After several years of negotiations with other SHIs, a GTB between the hospital and almost all statutory and private health insurers was launched in the region in 2020.