Relationship picking:the experience of Italian

Departmentsof Mental Health with working

acrossorganizations

Amelia CompagniSimone Gerzeli

Mara Bergamaschi

Center for Research in Health and Social Care Management

Inter-organizational relationships can havedifferent motives (resource dependence, efficiency, collaborative advantage, institutional norms and pressure)

Other aspects might facilitate IORs such as domain consensus, positive evaluation, ideological agreement, trust

Different motives might coexist according to thepartner/s involved

Inter-organizational relationships: motives and chioces

IOR can be at service and/or managerial/planning level

IOR can be informal or formalized

Frequency of communication and exchange is alsoa good indication of the intensity of relationship

Top executives/managers are critical in establishing these relationships and might filter them through thier own preferences

Inter-organizational relationships: modalities and actors

In mental health integration and coordination across service agencies and stakeholders are seen as a priority especially for systems that are targeted to SMI patients

Normally a need-perspective is presented as the justification for the creation of a mental health network

The case of mental health

The creation of a mh network and its composition might be influenced by :1. institutional pressure and policy enforcement2. role assumed by some actors (lead

organization)

The debate about the governance of mh networks has often concentrated on two alternatives: 1. mh core agency with centralized control 2. more loosely organized collaborative network

Mental health networks

The Department of Mental Health The Italian case presents a hybrid scenario

In the 90s Departments of Mental Health (DMHs) were created unifying all specialist mh services for a certain catchment area

DMHs need to provide four type of mh care:1. Acute care in psychiatric wards of general hospitals2. Community-based care (CMHCs, ambulatories,

domiciliary visists)3. Semi-residential care (day centers)4. Residential care with different degrees of supervision

DMH Directors

DMHs are governed by clinician-managers (DMH Directors) who:

1. Are nominated by LHA Director general among top medical doctors (= psychiatrists)

2. Might maintain a conspicuous clinical activity and responsibility for one

3. Are responsible for the DMH budget, workforce and are the recipients of policy indications elaborated at national and regional levels

4. Are supported by DMH Board with representation of the different professional categories but the almost totality of unit directors (middle management) is constituted by psychiatrists

DMHs are hierarchical structures

The study objectives

To assess the state, nature and intensity of the

IORs established by DMHsTo examine the strength of institutional pressure

and policy enforcement in the creation of IORs

To examine what kind of role the DMH has taken in respect to a larger mh network

To determine whether the role assumed and organizational nature of the DMH might have influenced the way IORs are constructed

Methods

Analysis of national and regional policy documents and laws (ministry of health, regional governments' databases). Content analysis and coding for:

1. motivation to create IORs and mh network; 2. role of DMH and DMH Director; 3. partner identity 4. ways and means of achieving this

National survey of DMH Directors 1. Closed questionnaire validated with 4 DMH Directors2. Construction of an address book3. E-mail, post and telephone recall

Findings: strength of policy enforcement Intra-organizational and inter-

organizational coordination are the prime duties assigned to DMHs (and to DMH Directors)

For intra-organizational: very little guidance on how to achieve this, the departmental structure is the solution

For inter-organizational: the DMH is the sector coordinator and proposed as the lead organization in the mh to be created

Motivations to create IORs: resolve fragmentation, respond to dissatisfaction, efficiency, and rarely “guarantee real effectiveness”

Lists of partners but some focus on: 1. Local Governments (social services, employement

and training/education, mh promotion)2. Third sector (voluntary associations, social cooperatives)

And then GPs and primary care, substance abuse and addiction services, hospital departments, children/adolescentsmh services

Findings: strength of policy enforcement

Findings: survey on DMH Directors

Sample description: Out of 205 DMHs we reached roughly

150 Of these 53 responded (35%)All but 4 Regions (out of 21) are

represented58% is in Northern Italy; big urban

contexts and smaller citiesGood representation of variety of DMH

dimensions and complexities

Intra-organizational coordination

frequent joint case

review and/or IT

system

clinical pathways

involvement of private

facilities in case review

involvement of private

facilities in data

sharing

collaboration protocols

with NPUs

Group 1 - - - - - Group 2 √ - 36,8% 46,7% 52,6% Group 3 √ √ 35,7% 45,8% 71,4%

9%36%55%

DMHs have attempted to create internal coordination mainly based on professional means

Multi-disciplinary is a priority in comparison to intra-organizational (see for instance private facilities)

Protocols with NPUs are mainly for client referral

We have concentrated on: local governments third sector GPs and primary care substance abuse and addiction

services (SASs)And two levels: - service

- managerial/planning

Inter-organizational relationships

Example 1: Local Governments

At service level: 1. client referral2. joint services (types, purpose)

At managerial level:1. Frequency (never, once a year,

delegated = low interaction; several times a year, once a month = high interaction)

2. Topics of discussion (planning, resource allocation)

3. Partecipation of DMH unit directors (middle management) to meetings

Example 2: SASs

At service level: 1. Shared patient diagnosis forms2. Joint clinical pathways for double diagnosis3. Clinical information sharing for joint patients4. DMH personel in detox clinics and

therapeutic communities

At managerial level:1. Frequency2. Topics of discussion 3. Partecipation of DMH unit directors to

meetings

% total sample

Never, once a year or delegated to others

(never)

Several times a year, every

month

No participation DMH middle management

DMH ↔ Local authorities 34,6% (8%) 65,4% 8,3% DMH ↔ Third sector 7,7% (2%) 92,3% 6,1% DMH ↔ GPs and primary care 34,6% (25%) 65,4% 31,4% DMH ↔ SAS services 43,1% (18%) 56,9% 29,4%

Interaction at managerial level

Topics: service planning and resource allocation with LGs vs. patients in joint treatment with SASs

13,5%

5,8%

21,2%

59,6%

Low service collaboration and low managerial

interaction

High service collaboration and low managerial interaction

Low service collaboration and high managerial

interaction

High service collaboration

and high managerial

interaction

Low service collaboration and low managerial

interaction

High service collaboration and low managerial interaction

Low service collaboration and high managerial

interaction

High service collaboration

and high managerial

interaction

3,8%

5,8%

9,6%80,8%

DMH ↔ LGs DMH ↔ TS

DMHs are selective partners

DMH ↔ GPs DMH ↔ SASs Low service collaboration

and low managerial interaction

High service collaboration and low managerial interaction

Low service collaboration and high managerial

interaction

High service collaboration

and high managerial

interaction

23,1%

26,9%

11,5%38,5%

34,6%

7,7%

28,8%

28,8%

Low service collaboration and low managerial

interaction

High service collaboration andlow managerial interaction

Low service collaboration and high managerial

interaction

High service collaboration

and high managerial

interaction

DMHs are selective partners

• Strong institutional pressure• Complementary services, domain consensus• Accessible resources

• Little institutional pressure• Unclear service boundaries, little domain consensus and positive evaluation• Inaccessible resources

DMH

LGs

TS

SASs

GPs

COLLABORATION

VERTICALINTEGRATION

FRUSTRATEDRELATION

AMBIGUOUSRELATION

Some suggestions

The DMH is a hierarchical structure but needs to deal with collaborative relationships

The DMH is an “imposed” network leader

To correct this:1. Move leadership onto a collaborative

structure2. Build DMH legitimacy3. Share leadership according to task