Joint working in community mental health teams: implementation of an integrated care pathway
01 Nov 2004-Health & Social Care in The Community (Health Soc Care Community)-Vol. 12, Iss: 6, pp 527-536
TL;DR: It is suggested that operational systems such as ICPs do not address and cannot overcome wider organisational barriers to integration of mental health services, and Integrated care pathways need to be developed with strategic input as well as practitioner involvement and ownership.
Abstract: Integration of community mental health services is a key policy objective that aims to increase quality and efficiency of care. Integrated care pathways (ICPs) are a mechanism designed to formalise multi-agency working at an operational level and are currently being applied to mental health services. Evidence regarding the impact of this tool to support joint working is mixed, and there is limited evidence regarding the suitability of ICPs for complex, community-based services. The present study was set in one primary care trust (PCT) in Scotland that is currently implementing an ICP for community mental health teams (CMHTs) across the region. The aim of the study was to investigate professionals' experiences and views on the implementation of an ICP within adult CMHTs in order to generate learning points for other organisations which are considering developing and implementing such systems. The study used qualitative methods which comprised of individual interviews with three CMHT leaders and two service development managers, as well as group interviews with members of four adult CMHTs. Data was analysed using the constant comparison method. Participants reported positive views regarding joint working and the role of an ICP in theory. However, in practice, teams were not implementing the ICP. Lack of integration at higher organisational levels was found to create conflicts within the teams which became explicit in response to the ICP. Implementation was also hindered by lack of resources for ongoing support, team development and change management. In conclusion, the study suggests that operational systems such as ICPs do not address and cannot overcome wider organisational barriers to integration of mental health services. Integrated care pathways need to be developed with strategic input as well as practitioner involvement and ownership. Team development, education about integration and change management are essential if ICPs are to foster and support joint working in integrated teams.
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TL;DR: ICPs are most effective in contexts where patient care trajectories are predictable; their value in settings in which recovery pathways are more variable is less clear and they may need supporting mechanisms to underpin their implementation and ensure their adoption in practice.
Abstract: Aim: Integrated care pathways (ICP) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities. ICPs are now being implemented across international healthcare arena, but evidence to support their use is equivocal. The aim of this study was to identify the circumstances in which ICPs are effective, for whom and in what contexts. Methods: A systematic review of high-quality randomised controlled trials published between 1980 and 2008 (March) evaluating ICP use in child and adult populations in the full range of healthcare settings. Results: 1.For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner. This can lead to improvements in service quality and service efficiency without adverse consequences for patients.2.ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocols thereby reducing variation in practice.3.ICPs can be effective in improving documentation of treatment goals, documentation of communication with patients, carers and health professionals.4.ICPs can be effective in improving physician agreement about treatment options.5.ICPs can be effective in supporting decision-making when they incorporate a decision-aide.6.The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction, where there is scope for improvement or where roles are new.7.Even in contexts in which health professionals are already experienced with a particular pathway, ICP use brings additional beneficial effects in directing professional practice in the desired direction.8.ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories.9.ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established.10.Depending on their purpose, the benefits of ICPs may be greater for certain patient subgroups than others.11.We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits.12.ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice, particularly in circumstances in which ICP use is a significant change in organisational culture.13.ICP documentation can introduce scope for new kinds of error.Conclusions ICPs are most effective in contexts where patient care trajectories are predictable. Their value in settings in which recovery pathways are more variable is less clear. ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services; their value in contexts where inter-professional working is well established is less certain. None of the studies reviewed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation.
148 citations
TL;DR: To support respite use there is a need for local action to be augmented at a community or population level by strategies to address attitudinal and resource barriers that influence sub-groups of the carer population who may be more vulnerable to service non-use.
Abstract: The use of respite services by carers has been shown to extend the length of time people with dementia can remain living in the community with family support. However, the use of respite services by informal carers of people with dementia is often low and does not appear to match carer need. To better understand how to address carers' unmet need for respite, the factors that impede respite service use must be identified. To achieve this, a narrative synthesis of published academic literature (1990-2011) was undertaken regarding factors associated with not utilising different types of respite services utilising Anderson's Behavioural Model of Service Use. The review reinforces the importance of the assessment and matching of services to the needs of individual carers and care recipients at the local level. It also highlights the need to move beyond care pathways for individuals. To support respite use there is a need for local action to be augmented at a community or population level by strategies to address attitudinal and resource barriers that influence sub-groups of the carer population who may be more vulnerable to service non-use.
104 citations
Cites background from "Joint working in community mental h..."
...However, the effectiveness of care pathways to improve coordination of care in the management of mental health conditions in the community environment remains uncertain (Rees et al. 2004)....
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TL;DR: While the logic of protocol-based care is algorithmic, in the reality of clinical practice, other sources of information supported nurses' decision-making process, which has significant implications for the political goal of standardisation.
Abstract: Aim. To explore how protocol-based care affects clinical decision-making.
Background. In the context of evidence-based practice, protocol-based care is a mechanism for facilitating the standardisation of care and streamlining decision-making through rationalising the information with which to make judgements and ultimately decisions. However, whether protocol-based care does, in the reality of practice, standardise decision-making is unknown. This paper reports on a study that explored the impact of protocol-based care on nurses’ decision-making.
Design. Theoretically informed by realistic evaluation and the promoting action on research implementation in health services framework, a case study design using ethnographic methods was used. Two sites were purposively sampled; a diabetic and endocrine unit and a cardiac medical unit.
Methods. Within each site, data collection included observation, postobservation semi-structured interviews with staff and patients, field notes, feedback sessions and document review. Data were inductively and thematically analysed.
Results. Decisions made by nurses in both sites were varied according to many different and interacting factors. While several standardised care approaches were available for use, in reality, a variety of information sources informed decision-making. The primary approach to knowledge exchange and acquisition was person-to-person; decision-making was a social activity. Rarely were standardised care approaches obviously referred to; nurses described following a mental flowchart, not necessarily linked to a particular guideline or protocol. When standardised care approaches were used, it was reported that they were used flexibly and particularised.
Conclusions. While the logic of protocol-based care is algorithmic, in the reality of clinical practice, other sources of information supported nurses’ decision-making process. This has significant implications for the political goal of standardisation.
Relevance to clinical practice. The successful implementation and judicious use of tools such as protocols and guidelines will likely be dependant on approaches that facilitate the development of nurses’ decision-making processes in parallel to paying attention to the influence of context.
93 citations
TL;DR: This review systematically reviewed all high-quality studies which have evaluated the impact of care pathway technologies on 'service integration' and its derivatives in stroke care to produce recommendations for ICP developers, users and evaluators.
Abstract: Background
Across the developed world, we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision. Integrated care pathways (ICPs) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration. ICPs map out a patient's journey, providing coordination of services for users. They aim to have: 'the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome'. The value for ICPs in supporting the delivery of care across organisational boundaries, providing greater consistency in practice, improving service continuity and increasing collaboration has been advocated by many. However, there is little evidence to support their use, and the need for systematic evaluations in order to measure their effectiveness has been widely identified. A recent Cochrane review assessed the effects of ICPs on functional outcome, process of care, quality of life and hospitalisation costs of inpatients with acute stroke, but did not specifically focus on service integration or its derivatives. To the best of our knowledge, no such systematic review of the literature exists.
Objectives
• To systematically review all high-quality studies which have evaluated the impact of care pathway technologies on 'service integration' and its derivatives in stroke care
To examine how elements of service integration are defined in such studies
To examine the type of evidence utilised to measure service integration
To analyse the weight of evidence used to support claims about the effectiveness of ICPs on improving service integration
To produce recommendations for ICP developers, users and evaluators.
Inclusion criteria
Types of participants
The review focused on the care of adult patients who had suffered a stroke. It included the full spectrum of services – acute care, rehabilitation and long-term support – in hospital and community settings.
Types of intervention(s)/phenomena of interest
Integrated care pathways were the intervention of interest, defined for the purpose of this review as 'a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and standardise the outcome orientated care'. Here 'multidisciplinary' is taken to refer to the involvement of two or more disciplines.
Types of outcomes
'Service integration' was the outcome of interest however, this was defined and measured in the selected studies.
Types of studies
This review was concerned with how 'service integration' was defined in evaluations of ICPs; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on 'service integration'. Studies that made an explicit link between ICPs and service integration were included in the review. Evidence generated from randomised controlled trials, quasi-experimental, qualitative and health economics research was sought. The search was limited to publications after 1980, coinciding with the emergence of ICPs in the healthcare context. Assessment for inclusion of foreign papers was based on the English-language abstract, where available. These were included only if an English translation was available.
Exclusion criteria
This review excluded studies that:
focused only on a single aspect of stroke care (e.g. dysphasia)
evaluated ICPs as part of a wider program of service development
did not make an explicit link between ICPs and service integration
did not meet the definition of ICP utilised for the purposes of the review
focused exclusively on the outcomes of variance analysis.
Search strategy
In order to avoid replication, the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Database
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68 citations
TL;DR: Assessment of the peer reviewed evidence on services/programs aimed at addressing youth to adult transitions in mental health services suggests little data exists on the effectiveness of transition services/ programs.
Abstract: Youth shifting to adult mental health services often report experiencing frustrations with accessing care that adequately replaces the youth services they had received. This systematic review assesses the peer reviewed evidence on services/programs aimed at addressing youth to adult transitions in mental health services. Findings suggest little data exists on the effectiveness of transition services/programs. While the available evidence supports meetings between youth and youth caseworkers prior to transitions occurring, it also verifies that this is not common practice. Other identified barriers to effective transitions were categorized as logistical (ineffective system communication), organizational (negative incentives), and related to clinical governance.
64 citations
Cites background from "Joint working in community mental h..."
...Joint working has shown mixed results for improving multi-agency collaboration in various health settings, including community mental health (Rees and Huby 2004)....
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References
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TL;DR: The degree to which integrated care pathways succeed in realising their potential for improving patient care is still uncertain, but enough evidence exists in their favour to justify more widespread evaluation of their impact.
Abstract: Integrated care pathways are structured multidisciplinary care plans which detail essential steps in the care of patients with a specific clinical problem. They have been proposed as a way of encouraging the translation of national guidelines into local protocols and their subsequent application to clinical practice. They are also a means of improving systematic collection and abstraction of clinical data for audit and of promoting change in practice. The degree to which they succeed in realising this potential for improving patient care is still uncertain, but enough evidence exists in their favour to justify more widespread evaluation of their impact. Here we describe integrated care pathways, show how to create and use them, and review the evidence of their effectiveness.
Many initiatives have been introduced in the past two decades to improve clinical effectiveness and thereby patient care. Foremost among these have been clinical guidelines and clinical audit. Concern is regularly expressed, however, that the commitment and enthusiasm of the groups publishing their experience is a major determinant of their success. There are also related concerns about the opportunity costs of audit and guidelines projects.
Guidelines development—literature review, critical appraisal, multidisciplinary consultation, and grading of recommendations by level of evidence—is labour intensive. Support is now available from several sources,1 2 but less attention and support is given to translating established guidelines into local management protocols and their subsequent implementation.3 even though the impact of clinical guidelines in improving clinical practice will largely be determined by progress in these areas. Audit projects often fail to realise their potential because the improved practice identified by the audit is not implemented or, if implemented, its effect is not evaluated.
Integrated care pathways—also known as coordinated care pathways, care maps, or anticipated recovery pathways—are task orientated care plans which detail essential steps …
839 citations
TL;DR: The system offers a set of guiding principles, based on the fact that, because knowledge and practice change continually when caring for patients, clinical records should be flexible and dynamic to accommodate these changes.
Abstract: Integrated care pathways (ICPs) offer a system of multidisciplinary care planning based around the principle of clinical audit and on the knowledge and practice of local clinical staff. The system offers a set of guiding principles, based on the fact that, because knowledge and practice change continually when caring for patients, clinical records should be flexible and dynamic to accommodate these changes. Benefits to be gained from implementing ICPs include improvements in communication between all disciplines involved, as well as between patients and carers. Optimal levels of free text are ensured through the pre-printed record having an outcomes-based focus and through incorporating the idea of exception-based recording. Issues to be considered include individuality and confidentiality. Benefits to be gained include increased patient satisfaction, a reduction in documentation and inappropriate lengths of stay.
453 citations
TL;DR: It was revealed that although integrated care pathways led to improved outcomes for the health care trust there was little evidence to suggest that interprofessional relationships and communication were enhanced and key factors in discharge delays appeared to be organizational rather than professional.
Abstract: This paper reports on the evaluation stage of an action research project on interprofessional collaboration in discharge planning Findings from interviews with health care professionals working in the acute sector had revealed concerns about discharge planning and multidisciplinary teamwork In the United Kingdom the National Health Service (NHS) Plan has reinforced the need for an integrated approach to health care Effective health care integration requires effective communication, teamwork and the commitment to deliver integrated care Integrated documentation is a key strategy for enhancing interprofessional collaboration and reducing the isolation of professionals, and has been successfully implemented in a range of health care settings Presented with the concerns about the collaborative process in discharge planning, an action research strategy was chosen to bring about change in an orthopaedic ward in one London teaching hospital This paper will evaluate the implementation of an integrated care pathway with fractured neck of femurs in one London teaching hospital Care pathways facilitate the management of defined patient groups using interdisciplinary plans of care The emphasis will be on understanding whether integrated care pathways enhance and develop interprofessional collaboration and enable effective information access and flow across the professions and the organization The criteria for evaluation, forming the hypotheses of the study, were that interprofessional nonverbal and verbal communication would be enhanced and that interprofesisonal collaboration would increase Methods of evaluation used were: (i) stakeholder interviews, (ii) interprofessional audit and (iii) analysis of the variances from the integrated care pathway The evaluation revealed that although integrated care pathways led to improved outcomes for the health care trust there was little evidence to suggest that interprofessional relationships and communication were enhanced Furthermore, key factors in discharge delays appeared to be organizational rather than professional
231 citations
TL;DR: An investigation of three interdisciplinary mental health teams concludes that boundaries between professions are actively encouraged by the experience of interdisciplinary modes of working.
Abstract: This paper reports on an investigation of three interdisciplinary mental health teams. The discussion of the responses highlights the boundaries that exist between different professional roles and areas of responsibility. Whereas there is some evidence of role blurring, which was welcomed by a few respondents, others sought to preserve their own professional identity within the multidisciplinary environment. In a paradoxical sense, the lack of managerial direction and the encouragement of generic working seemed to make some respondents all the more insistent on separate professional identities. We conclude that, far from being a relic of the past or a product of ‘ingrained attitudes’, boundaries between professions are actively encouraged by the experience of interdisciplinary modes of working.
219 citations
TL;DR: Discussions revealed and explored four key reasons why mental health professionals working within teams are reluctant to comply with operational directives.
Abstract: This paper draws upon an initiative by the Centre for Mental Health Services Development to establish a multi-professional dialogue between senior mental health care professionals in order to explo...
144 citations