Introduction: Service delivery to people with combined addictions and mental health problems is a major challenge for integration of health, social care and welfare services. In Norway, services to this group are delivered by hospital specialist services, municipal primary social care and medical services (including family doctors), together with the national social security and welfare agency. This study aims to identify vulnerable transitions in the service system for patients with combined addiction and mental health problems, and to explore how these transitions are shaped by organisational and relational framework conditions. Several factors need to be considered if we are to establish integrated care arrangements: who should collaborate, how they collaborate and how the collaboration is organised.
Theory/method: Structure, process, roles and relationships are factors that can be used to describe co-ordination. Different forms of co-ordination can be placed on a scale of intensity from simple to complex forms of collaboration:
- Information exchange
- Case coordination
- Interagency meetings
- Multidisciplinary teams
- Pooled budgets
Complex collaboration: Information exchange represents the most simple model of collaboration, whilst pooled budgets is the most complex model incorporating elements from all the other forms.
Mapping of vulnerable transitions was carried out in a workshop with participation from user and informal carer representatives, front line staff and managers from municipal purchasing and provider departments, together with staff and managers from addictions and psychiatric out-patient departments. Data was collected in six semi-structured group interviews, and recordings of discussions in six groups centring on transitions in pathways of care.
The analysis centres on participants’ descriptions of vulnerable transitions for service users with addictions and psychiatric problems and proceeded according to the principles of systematic text condensation: 1) total impression 2) identifying and sorting meaning units 3) condensation and 4) synthesizing.
Results: Several factors create vulnerable transitions for this patient group:
Findings suggest that exchange of information is the most common form of collaboration and most participant considered it sufficient. Communication is written and takes the form of referrals and written responses to these. The information exchange takes place in a fragmented system where the different services have their own and limited area of responsibility. This system does not address the complex needs of this user group. A number of “grey zones” emerge in practice, where responsibility is not clearly defined and management stalls.
Service users, informal carers and service providers all draw attention to enhanced use of one appointed coordinator to reduce vulnerable transitions. In Norway, co-ordination of care is accomplished through Individual Care Plans, with a care co-ordinator whose responsibility it is to involve relevant services and ensure holistic arrangements of management and support. Findings suggest that this arrangement seldom works. The time that elapses from the identification of a need to the introduction of a service is often very long. A particular challenge is housing for people who are discharged from institutional care because the municipal care co-ordinator is not involved at an early enough stage.
Vulnerable transitions exist also at the individual level. Service users experience change of therapist or case worker as a problem because they have to rebuild relationships of trust and confidence. Collaboration through personal contact across services is also set back with personnel changes. Locating a new therapist or case worker takes time and makes collaboration more difficult.
Discussion: Exchange of information is the most basic form of collaboration. However, it is not adequate for the support and management of complex conditions such as combined addictions and psychiatric problems. A simple exchange of information does not facilitate sharing and discussion of different professional perspectives. A particular challenge is to combine expertise in addiction and psychiatry; as separate and combined conditions. The study shows that formal and informal contact reinforce each other. Arrangements like common courses and guidance may reduce the users’ experience of vulnerability when transitions take place.
Housing is a key arena for service provision, whether from hospital out-patient, in-patient, or community based municipal services. A person’s housing situation determines to a large extent how services can be organised and delivered. Housing needs to be on the agenda at an early stage in a care process so that possible housing needs are identified and the service responsible for housing provision is involved in time. According to experiences, local service providers are best suited for assessing appropriate housing needs.
Conclusion: Our analysis suggests that vulnerable transitions in the service area studied must be addressed through more complex forms of collaboration than exist at the moment. The main challenge is not to find relevant measures but to make sure someone takes responsibility to implement them. Some measures are statutory and in any case well known to the services. It is also important to establish robust, transparent and predictable relationships and structures among services and between the service system, users and unpaid carers.
Vold Hansen, Gunnar, Catharina Bjørkquist, Guro Øyen Huby, and Lasse Johnsen. 2016. “Tricky Transitions”. International Journal of Integrated Care 16 (6): A101. DOI: http://doi.org/10.5334/ijic.2649
Vold Hansen, Gunnar, Catharina Bjørkquist, Guro Øyen Huby, and Lasse Johnsen. “Tricky Transitions”. International Journal of Integrated Care 16, no. 6 (2016): A101. DOI: http://doi.org/10.5334/ijic.2649