Sometimes neither the service user nor the municipal healthcare personnel interact in relation to the discharge from the CMHC, even where they do not believe that the service user is ready to be discharged. There are also some who want to stay longer than the healthcare personnel think is appropriate:
‘Many service users very much enjoy their time at the CMHC and do not want to go home to solitude. They feel settled, enjoy the social atmosphere, they are chauffeured around and fed well.’ (CMHC healthcare worker)
Upon discharge, CMHC and municipal healthcare personnel help the service user to establish contact with relevant services. They can also prepare an individual plan (IP) together with the service user. The IP is a coordination tool that contains decisions on the health services selected for the individual. The CMHC healthcare personnel have faith in the IP, even though it is not always used:
‘Using an IP can provide a shared understanding of the individual's goals, resources and service needs, and ensure that there is always someone who is responsible for providing service users with the services they are entitled to.’ (CMHC healthcare personnel)
Although the health services provided by the CMHC and municipalities are not coordinated through an IP, service users can avail themselves of home-based services provided by the CMHC and municipality. The CMHC offers group activities that can build good relationships between healthcare personnel and service users, as well as prevent a deterioration in service users’ mental health:
‘During the group activities, we spend time together when service users are feeling better and staying at home. This enables us to initiate interventions at an early stage should their mental health decline, and ensures the follow-up of service users who do not see a therapist regularly.’ (CMHC healthcare worker)
The CMHC healthcare personnel are committed to tailoring the service provision to the individual user and to interacting with the municipalities in order to provide optimum support for the service user. Making use of the CMHC’s services can be crucial for service users:
‘I’ve thought about whether we make some people dependent on the CMHC when they can use the municipality’s services, but have discovered that the service users’ coping skills vary. Many struggle so much with their social skills that they do not benefit sufficiently from the services offered by the municipalities, and they need services in both places.’ (CMHC healthcare worker)
The study documents that CMHC and municipal healthcare personnel coordinate and safeguard service user involvement for persons with an SMI when designing and implementing their service provision.
Involvement of persons with an SMI in care coordination entails service users taking part in the planning of CMHC admissions, in care coordination meetings at the CMHC and in the municipalities, and in the planning of discharges from the CMHC to the municipalities.
This means that healthcare personnel facilitate transitions and the exchange of information, while at the same time safeguarding service users’ wishes and needs for services (6). The study documents that service user involvement in care coordination is challenged when the healthcare personnel from the municipalities and the service user are not involved in assessing whether there is a basis for admission to the CMHC.
It is also challenging when the service user does not participate in care coordination meetings or in the choice of services, and when there is disagreement between the healthcare personnel about accountability or responsibility, and service provision.
The healthcare personnel are keen to coordinate with the municipalities on the responsibility for the service users and not to distinguish between the CMHC’s and the municipalities’ patients.
In the case of planned admissions, the service user participates in assessing the timing and purpose of the admission. This enables the healthcare personnel to safeguard the wishes and needs of the individual in relation to admission (4, 6, 7, 21). For user-controlled places at the CMHC, service users are admitted when they feel that their mental health symptoms are increasing.
User-controlled admissions have been shown to reduce the duration of stays and the number of patients being hospitalised involuntarily at CMHCs. One important explanation is that people feel safe when help is available (22, 23).
The results show that the healthcare personnel are keen to coordinate with the municipalities on the responsibility for the service users and not to distinguish between the CMHC’s and the municpalities’ patients. Shared responsibility for service users in need of coordinated services strengthens the coordination across service levels (6, 24). It may therefore be appropriate not to specify who has the main responsibility for service users in the care coordination.
The results also show that care coordination often takes place through cooperation and shared responsibility meetings with healthcare personnel from the CMHC and the municipalities. Healthcare personnel arrange the meetings in a way that encourages the individuals to participate, and this approach is supported by research (7, 25).
The study found that service users participate in the discharge planning and follow-up at home. This finding is consistent with McDonald et al. (6), who stress that healthcare personnel should register the service users’ wishes and service needs and provide them with information on relevant services at the point of transition.
The results show that service users received services from the CMHC at home. This facilitated coordination and continuity in the services, and led to an optimum service provision from the service user’s perspective (14). The services are integrated despite the CMHC and the municipalities having different areas of funding and responsibility (5).
The results document that healthcare personnel can face challenges in safeguarding service user involvement in care coordination. Challenges arose when the service user and healthcare personnel from the municipalities did not participate in the CMHC’s assessment of the need for admission in the case of emergency admissions.
Research shows that diagnoses and symptoms often serve as a guide for the basis for admission, and that the level of competence is perceived by some to be higher in the CMHCs than in the municipalities (4, 21). According to the results, this perception may be due to the fact that the CMHC healthcare personnel lack knowledge about the municipality’s competence and areas of responsibility and about which measures should be implemented for service users during periods of poor mental health.
Consequently, disagreements can arise about who is responsible for persons with an SMI in various stages of the illness (21). Shared meeting places for CMHC and municipality healthcare personnel can lead to greater knowledge and a closer understanding of each other’s roles, competences and areas of responsibility in the care coordination (6, 24).
Another challenge arises when CMHC healthcare personnel consider the service user to have completed their treatment without involving them or the municipal healthcare personnel. This can happen if the treatment has not produced the desired effect. The municipality then assumes responsibility for service users whose mental illness symptoms are just as severe as when they attended the CMHC (26).
The results show that it can be challenging for healthcare personnel to involve service users in the coordinated discharge process.
Research has documented that several Norwegian municipalities do not have an adequate service provision for persons with an SMI (14, 15). The symptoms of this group may be so severe that they are unable to make use of the home-based services offered by the municipalities or to take their medication after they have been discharged from the CMHC (14, 27, 28).
The lack of post-discharge services and activities is a challenge that can lead to service users not following up on the treatment, and which can reduce their quality of life (12).
The results show that it can be challenging for healthcare personnel to involve service users in the coordinated discharge process. Some service users do not want to be followed up at home, even although the healthcare personnel encourage them to be involved in choosing services and receiving help. Research shows this may be due to stigmatisation, bad experiences from previous follow-up and a lack of insight into their illness (14, 15).
The results document the importance of a service provision that is tailored to the individual user’s wishes and needs. A tailored service provision may result in service users accepting follow-up at home (6, 14). As part of their service provision and care coordination, the CMHC and municipalities can offer peer support for persons with an SMI with a view to improving their quality of life (29).
The peer support initiative entails persons who have worked through their own experience with mental illness using this experience to help others. The peers can work at an activity centre, as part of a therapeutic community, or with research and education. They can also just sit down and talk to the service users (13, 25, 30). Measures that support self-care, social and cognitive skills, lifestyle and medication can also strengthen the service user’s involvement in the care coordination (6, 29).
The IP is a tool for coordination and service user involvement that includes decisions on the health services selected for the service user. It ensures that healthcare personnel safeguard service users’ wishes and needs for services at all times (6).
The results of this study show that the IP has not always been used in care coordination, despite healthcare personnel having faith in it. Instead, the CMHC and municipal healthcare personnel often followed different plans, which may well have reduced the quality of the services (4, 27).
Strengths and limitations
The study was conducted in a research collaboration in which three researchers participated in all phases, which strengthens the credibility of the study (18). Another strength is that the interpretations of the dataset were linked to the study’s purpose and the framework for care coordination in the analysis work (6, 19).
It is also a strength that the participants were managers and healthcare personnel from four municipalities and all three wards at a CMHC with experience in coordinating and safeguarding the involvement of individuals with an SMI.
One limitation of individual interviews is that participants can withhold information or give strategic answers. A limitation of the sample in the study is that it did not include persons with an SMI or healthcare personnel from a wider range of CMHCs and municipalities. This would have produced a larger sample with more perspectives, but would also have increased the complexity of the study. The perspectives of persons with an SMI in connection with care coordination are an important area for future research.
The study describes how healthcare personnel from one CMHC and four municipalities have safeguarded service user involvement in their coordinated work with admissions, care coordination meetings and the design of services at the point of discharge and when the service user is at home.
Service user involvement in care coordination is made more difficult when the CMHC makes unilateral decisions on the basis for admission and treatment needs, when the individual does not want to participate in care coordination meetings and the choice of services, and when CMHC and municipal healthcare personnel disagree on accountability or responsibility and which measures to implement.
The implication of the study on practice is that meeting places where healthcare personnel from the specialist and municipal health services discuss care coordination challenges can increase knowledge about each other’s competence and areas of responsibility.
In order to empower persons with an SMI in the care coordination, it is important that healthcare personnel and the service user are included in decision-making processes and that decisions are tailored to the individual user. Decisions must take into account the service user’s social and cognitive skills, and safeguard their mental and somatic health and medication.
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