Inter-agency Teams: Organisational Culture
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Inter-agency Teams: Organisational Culture

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Mental Health Shared Care between private and public providers poses specific logistic and cultural issues. This powerpoint based on my Masters Thesis, examines the use of a culture carrier.

Mental Health Shared Care between private and public providers poses specific logistic and cultural issues. This powerpoint based on my Masters Thesis, examines the use of a culture carrier.

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  • The integration of the various primary care services in Australia into a coherent system of care that delivers for patients, providers and funding bodies remains a major problem. In the past decade, shared care has been seen as one solution. It was a major item in the Second National Mental Health Plan in 1998 and in 2005, the SA Government put $2.75 million into shared care which has created a variety of models across the fourteen Divisions of General Practice in SA. (refer slide) From the 14 Division models which are very different from each other, I started to look what was shared care, and if it is so obvious to everyone that it needs to happen, why doesn’t it already happen, why did it need to be specifically funded?
  • What the literature doesn’t say is what a positive organisational culture for shared care IS.
  • The blue circles represent the provision of care. (talk through slide) The idea of shared care is that the care is truly seamless from the point of view of the consumer, so that it feels like one unit of care. Now given that there are about 1800 GPs in SA and many fewer community mental health services, it is not feasible to have a true one on one partnership like this. So I next looked at how they were organised and what the literature says about the barriers to shared care occurring spontaneously in any significant size.
  • Then I looked at the literature for barriers that were culture-based falls loosely into 7 categories: Organisational barriers refer to how the organisations are set up, the different funding with service-based funding for GPs whereas community mental health service staff are salaried – so GPs are not paid to discuss cases. Care planning and case conferencing MBS item numbers address this somewhat. Trust and respect refers to a number of factors. GPs tend to refer to specialists they know, and have confidence in the ability of. In shared care they refer to an organisation where they don’t actually know who will see their client. Relationships between GPs and community mental health services described as one of apprehension, the ‘high degree of suspicion and animosity’. Paradigm / perspective refers to different ideologies and goals, differing maps of the worlds, different clinical paradigms, and a distrust of other groups’ perspectives. There are also the paradigms of the GP as a generalist versus mental health services as specialists, and the GPs as a longitudinal view of the patient, whereas specialist mental health services often have a time-limited or crisis intervention view. Roles refers to the intersection of roles represented in shared care, and particularly the idea of case management – who has control over the consumer’s whole care. Links closely to power. Knowledge refers to a profession’s body of knowledge as key to defining professional identity, and lack of understanding of other professional knowledge bases leads to a lack of trust in professional ability and concerns about the ability of other partners to manage particular clients or conditions. Links closely to trust. Power refers to fear of losing the overall management of consumers’, loss through removal of power and responsibility. Shared care is largely about sharing power and responsibility in a negotiated model. For clinicians used to having autonomous decision making power, entering into the shared care agreement might represent a compromise, and if they are losing power to a clinician whose perspective they do not fully understand or respect, this can be a significant barrier And finally, perceptions further complicate all of these factors – not only is there how one side is feeling about the other, there is also what they think the other is thinking about them. Participants report the perception that GPs did not want to walk to the mental health nurses because they ‘aren’t good enough’, that GPs did not have the time, interest or skills and do not ask for help from nurses (ie: don’t recognise their skill level).
  • Maps of the consumer journey may include referral criteria, communication points and methods etc. Agreed defined roles address a number of the issues mentioned on the previous slide such as power, roles intersection. These two items may be formally recorded and agreed in a Memorandum of Understanding or less formally in some form of working agreement . Shared records are an ideal that is currently not being taken up much due in part to the barriers of , ownershp of records and also issues regarding the Privacy Act. Shared care planning occurs quite frequently with each provider getting a copy of the plan. Face to face options include joint training, regular meetings and joint assessments, so are often less about the shared care model and more about trying to build relationships between clinicians. Of course this only works to the extent that they attend and actually engage with each other, not sit and talk to their own group, or stay away. And finally, the link that seems most promising, the coordinator, who is a central point of contact for both sides in engaging in shared care.
  • So the benefits of having a coordinator are that each side of the shared care agreement has to make the least possible change and still have it work. It also narrows the number of people each one needs to engage with down to one instead of a multitude. However, it does mean that there is a requirement for funding for this position in order for the model to be sustainable, and essentially it reinforces the idea that each side can continue as they are - there is no fundamental systemic change. What I would like to find is what sort of culture and accommodations need to exist in order to have shared care work without the coordinator, but to date I am finding that it doesn’t work, at least in an ongoing way to any large extent.

Inter-agency Teams: Organisational Culture Inter-agency Teams: Organisational Culture Presentation Transcript

  • The impact of organisational culture on GP–mental health service shared care models. Louise Miller Frost October 2006
  • Rationale for Shared Care
    • Addresses the Commonwealth / State funding split
    • More effective / efficient use of resources
    • Addresses gaps and duplications in service in multi-provider environment
    • Better (safer) outcomes for consumers
  • The literature says…..
    • A positive organisational culture is a requirement for shared care to work
    • Lack of a positive organisational culture is a barrier to shared care working
  • Organisational Culture
    • Edgar Schein: shared reality of participants
    • a metaphor enables examination and analysis of symbolic aspects of organisational life, with a focus on shared systems of meaning, values, norms and belief systems, relationships within the organisation and with external entities
    • (Ref 1)
  • Research Questions 1. It is assumed that mental health services and GPs don’t naturally work together in shared care. What is the evidence? 2. What is it about the cultures of community health services and GPs that doesn’t automatically enable shared care? What are the barriers to shared care? 3. When Mental Health Services and GPs work in shared care models, how do they perceive and value what is happening? 4. What are the cultural and other factors that make the difference between whether a shared care model works or does not work? 4.1 Does it require having a coordinator whose dedicated job is to facilitate the communication, transfer of care and working together? 4.2 Is there a level of ‘teamness’ required to make shared care work? (ie: shared culture) 4.3 What factors build in unsustainability?
  • Table 1: Common models of care (refs 2-5)
  • Barrier categories
    • Organisational barriers : funding, structures
    • Trust, respect
    • Paradigm / perspective
    • Roles - clash of roles / uncertainty about roles
    • Knowledge
    • Power
    • Perceptions of each other
    • (Refs 6-17)
  • How are these barriers addressed in working models?
    • Maps (pathways)
    • Defined roles
    • Shared records
    • Face to face options
    • Coordinator
  •  
  • Or in another way……. GPs CMHS GPs CMHS With coordinator Without coordinator
  • Where to from here
    • Continuing to examine shared care literature including grey literature
    • Semi-structured qualitative interviews
    • - GPs
    • - CMHS staff
    • - Senior MHS managers
    • - Shared care coordinators
    • Relationships / perceptions of each other / understanding of roles
    • Shared care and non-shared care
  • References
    • 1. Morgan G, Images of Organization, 1986, SAGE Publications Inc, UK. Pp134-136
    • 2. Holmwood C, Groom G, Nicholson S, 2001, Mental Health Shared Care in Australia 2001: A report for the Commonwealth Department of Health and Ageing. Primary Mental Health Care Australian Resource Centre, Department of General Practice, Flinders University and Australian Divisions of General Practice. June 2001
    • 3. Keks NA. Altson BM. Sacks TL. Hustig HH. Tanaghow A. Collaboration between general practice and community psychiatric services for people with chronic mental illness. Medical Journal of Australia. 1998. pp 8-13.
    • 4. Cochrane Collaboration. On-site mental health workers in primary care: effects on professional practice (Review). 2006
    • 5. Kasperski MJ, Rockman P. A Shared Care Network: Enhancing Mental health Services in Ontario. 2000.
    • http://ocfp.on.ca/local/files/Proposals/enhancing%20mental%20health%20services%20proposal.pdf
    • 6. Douglas S, Machin T, 2004, A model for setting up interdisciplinary collaborative working in groups: lessons form an experience of action learning. Journal of Psychiatric and Mental Health Nursing, 2004; 11: 189-193
    • 7. Holmwood C, Groom G, Nicholson S, 2001, Mental Health Shared Care in Australia 2001: A report for the Commonwealth Department of Health and Ageing. Primary Mental Health Care Australian Resource Centre, Department of General Practice, Flinders University and Australian Divisions of General Practice. June 2001
    • 8. National Mental Health Strategy Evaluation Steering Committee, for the Australian Health Ministers’ Advisory Council. Evaluation of the National Mental Heath Strategy: Final Report. Canberra: Mental Health Branch, Commonwealth Department of Health and Family Services, 1997, p21
    • 9. McCann TV, Baker H. 2003. Models of mental health nurse-general practitioner liaison: promoting continuity of care. Journal of Advanced Nursing. 41 (5), 471-479.
    • 10. Mueller J, Neads P, 2005. Allied health and organisational structure: massaging the organisation to facilitate outcomes. NZ Journal of Physiotherapy. July 2005, 33;2: 48-54
    • 11. Harmon K, Carr VJ, Lewin TJ. 2000 Comparison of integrated and consultation-liaison models for providing mental health care in general practice in New South Wales, Australia. Journal of Advanced Nursing. 32 (6) 1459-1466
    • 12. Appleby NJ, Dunt D, Southern DM, Young D, General Practice Integration in Australia. Australian Family Physician , 1999; 28: (8) 858-863
    • 13. Duckett SJ, 2005, Interventions to Facilitate Health Workforce Restructure. Australia and New Zealand Health Policy 2005, 2:14
    • 14. Appleby NJ, Dunt D, Southern DM, Young D, General Practice Integration in Australia. Australian Family Physician , 1999; 28: (8) 858-863
    • 15. Duckett SJ, 2005, Interventions to Facilitate Health Workforce Restructure. Australia and New Zealand Health Policy 2005, 2:14
    • 16. Bisset K. 2006. The Great Turf Tussle. Medical Observer, 8 Sept 2006, p17-18.
    • 17. Degeling, P, Kennedy, J, Hill, M, Carnegie, M, Holt, J 1998 Professional Subcultures and Hospital Reform. The Centre for Hospital Management and Information Systems Research, University of NSW, Sydney Australia