Implementing new models of integrated mental health care: what impacts effective performance?

摘要

Introduction : In the Metro South geographical area in South East Queensland, the Logan Beaudesert Wellbeing Program was developed with the goal of implementing interdisciplinary approaches within a multidisciplinary team to increase wellbeing of people who experience mental illness alongside the overarching goal of building a healthier community. This study reports on the implementation process and highlights how existing structures within health systems impact how staff are able to engage with new models of care that aim to re-orient care. Theory / Methods : Data collection and analysis was guided by Normalisation Process Theory; a mid-range theory concerned with integration and embedding of practices in existing systems, which posits that to become normalised, new practices must ‘fit’ well within the existing patterns of the workforce, the organisation and the prevailing methods of delivering care. All staff employed to implement the model of care were invited to participate in a face-to-face semi-structured interview prior to and six months post implementation of the model of care. Interviews were digitally recorded and transcribed verbatim. Two researchers then thematically analysed the data using techniques of initial coding, categorisation and constant comparison until the most salient themes were identified and all data were taken into account. Results : Twenty-four staff participated in the initial interviews and twenty-one participated in the post-implementation interviews. Sixteen participants participated in both interviews. Staff were passionate and enthusiastic about the model of care and had high expectations of its capacity to facilitate quality health and wellbeing outcomes. As implementation progressed, there was an increasing pressure to perform and to meet pre-defined cost effectiveness measures. Existing structures impacted performance – especially resource, governance and leadership structures as well as historical and segregated ways of working. Discussion : Fuelled by enthusiasm from key decision makers and stakeholders, participants had huge expectations of the model of care; viewing it as a real option to improve mental health and wellbeing outcomes in the community. However, greater focus upon meeting key performance indicators such as hard hospital utilisation and cost-efficiency, which were not synonymous with person-centred care, compromised participants’ fidelity to the model, hence making consumers susceptible to being affected. In addition, because leadership and governance boundaries were unclear, unrest and confusion occurred. Conclusion : Although participants passionately endorsed the new model of care, pre-existing structures impacted the way that the program was implemented. Thus, when new teams are employed to deliver new models of care, they need to establish ways of working together, understand and negotiate their place within the health-culture landscape, and broker support from numerous stakeholder groups and individuals. Lessons Learned : When evidence-based and aspirational models of person-centred care are implemented, organising structures such as cost, time, resources, and established lines of governance and accountability are powerful forces that need to be factored into outcome measures. Limitations : Generalisability of the findings from this project is limited because of the nuances of the context in which the LBWP was implemented. Future Research : Future research regarding ways of adopting person-centred practice within existing teams and existing cultures is required.