Relationship picking: the experience of Italian Departments of Mental Health with working across

1. Relationship picking: the experience of Italian Departments of Mental Health with working across organizations Amelia Compagni Simone Gerzeli Mara Bergamaschi Center for Research in Health and Social Care Management

2. Inter-organizational relationships: motives and chioces • Inter-organizational relationships can have different 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 the partner/s involved

3. Inter-organizational relationships: modalities and actors • IOR can be at service and/or managerial/planning level • IOR can be informal or formalized • Frequency of communication and exchange is also a good indication of the intensity of relationship • Top executives/managers are critical in establishing these relationships and might filter them through thier own preferences

4. The case of mental health • 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

5. Mental health networks • The creation of a mh network and its composition might be influenced by : • institutional pressure and policy enforcement • role assumed by some actors (lead organization) • The debate about the governance of mh networks has often concentrated on two alternatives: • mh core agency with centralized control • more loosely organized collaborative network

6. 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: • Acute care in psychiatric wards of general hospitals • Community-based care (CMHCs, ambulatories, domiciliary visists) • Semi-residential care (day centers) • Residential care with different degrees of supervision

7. DMH Directors • DMHs are governed by clinician-managers (DMH Directors) who: • Are nominated by LHA Director general among top medical doctors (= psychiatrists) • Might maintain a conspicuous clinical activity and responsibility for one • 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

8. The study objectives To assess the state, nature and intensity of the IORs established by DMHs • To 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

9. Methods • Analysis of national and regional policy documents and laws (ministry of health, regional governments' databases). Content analysis and coding for: • motivation to create IORs and mh network; • role of DMH and DMH Director; • partner identity • ways and means of achieving this • National survey of DMH Directors • Closed questionnaire validated with 4 DMH Directors • Construction of an address book • E-mail, post and telephone recall

10. 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

11. Findings: strength of policy enforcement • Motivations to create IORs: resolve fragmentation, respond to dissatisfaction, efficiency, and rarely “guarantee real effectiveness” • Lists of partners but some focus on: • Local Governments (social services, employement and training/education, mh promotion) • Third sector (voluntary associations, social cooperatives) And then GPs and primary care, substance abuse and addiction services, hospital departments, children/adolescents mh services

12. 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 represented • 58% is in Northern Italy; big urban contexts and smaller cities • Good representation of variety of DMH dimensions and complexities

13. Intra-organizational coordination 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

14. Inter-organizational relationships We have concentrated on: • local governments • third sector • GPs and primary care • substance abuse and addiction services (SASs) And two levels: - service - managerial/planning

15. Example 1: Local Governments • At service level: • client referral • joint services (types, purpose) • At managerial level: • Frequency (never, once a year, delegated = low interaction; several times a year, once a month = high interaction) • Topics of discussion (planning, resource allocation) • Partecipation of DMH unit directors (middle management) to meetings

16. Example 2: SASs • At service level: • Shared patient diagnosis forms • Joint clinical pathways for double diagnosis • Clinical information sharing for joint patients • DMH personel in detox clinics and therapeutic communities • At managerial level: • Frequency • Topics of discussion • Partecipation of DMH unit directors to meetings

17. Interaction at managerial level • Topics: service planning and resource allocation with LGs vs. patients in joint treatment with SASs

18. 13,5% 3,8% 21,2% 9,6% 59,6% 80,8% 5,8% 5,8% DMHs are selective partners DMH ↔ LGs DMH ↔ TS Low service collaboration and low managerial interaction Low service collaboration and low managerial interaction High service collaboration and low managerial interaction High service collaboration and high managerial interaction High service collaboration and high managerial interaction High service collaboration and low managerial interaction Low service collaboration and high managerial interaction Low service collaboration and high managerial interaction

19. DMHs are selective partners DMH ↔ GPs DMH ↔ SASs Low service collaboration and low managerial interaction Low service collaboration and low managerial interaction 34,6% High service collaboration and high managerial interaction High service collaboration and low managerial interaction High service collaboration and low managerial interaction High service collaboration and high managerial interaction 23,1% 28,8% 7,7% 11,5% 38,5% 26,9% 28,8% Low service collaboration and high managerial interaction Low service collaboration and high managerial interaction

20. FRUSTRATED RELATION COLLABORATION SASs LGs • Little institutional pressure • Unclear service boundaries, • little domain consensus and • positive evaluation • Inaccessible resources • Strong institutional pressure • Complementary services, • domain consensus • Accessible resources DMH TS GPs AMBIGUOUS RELATION VERTICAL INTEGRATION

21. 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: • Move leadership onto a collaborative structure • Build DMH legitimacy • Share leadership according to task