TUE 2:30 PM Parallel Session: Mental Health Care Systems

Full Report: Session 115 on mental health care systems had 31 attendees. Three papers were presented.

Investigations by Eric Wolstenholme, Douglas McKelvie and their colleagues at Symmetric System Dynamics as well as a client resulted in Emerging Opportunities for System Dynamics in UK Health and Social care: The Market-Pull for Systemic Thinking. From the background of their work in the UK, the authors presented two issues which promise to be fruitful areas of work for system dynamics modeling in health care: service-line reporting and health needs analysis.

These areas provide an entry point into the use of system dynamics modeling which avoid some of the difficulties of presenting composite models of health systems which might be of a complexity unsuited to inform the mental models of health practitioners. Service-line reporting focuses on the analysis of patient pathways as service lines. The stock-flow structure of system dynamics is well suited for this task. System dynamics can help to develop a shared understanding between different providers and allows testing financial and operational outcomes under different policy or demand scenarios.

Health needs analysis is motivated by the desire to better target service delivery to patient need. Models to help in that task need to combine the progression of needs over time as well as the movement of patients through treatment states or patient pathways. The number of patients in different stages of need is often known far less than the number of patients receiving different types of services. While past models often focused on either needs or service progression, matrix models combining needs and service progression are becoming attractive.

The authors presented the application of this thinking in planning services and stepped care services for depression and anxiety (involving case management and psychological therapies) in primary health care. The authors concluded that system dynamis can support service-line reporting and health needs analysis which both provide an opening for the further spread of system dynamics into health services.

Peter Hovmand, from Washington University in St. Louis, presented a paper written with six co-authors both from his university and mental health practitioners. The paper highlighted the interchange between science and policy practice made possible in a number of related projects focusing on mental health service. These projects include a NSF funded project on the impact of innovation implementation on organizational performance and a number of consultancy projects for the Missouri Department of Mental Health to support policy work on a fundamental transformation of services towards a consumer- and family-driven mental health system.

Participants in both projects overlapped: the previous positive experience with system dynamics motivated them to participate in the subsequent work. The modeling work allowed the team from Washington University to assemble a diverse community in the mental health sector with an appreciation of system dynamics and an interest in carrying forward system dynamics related work. They have engaged with that community not only in research projects, but have also participated in other ways. Close engagement with the practitioners allowed the research group to develop a detailed understanding of mental health issues at the state and local level. At the same time, the work helped decision makers to communicate with each other and improve their mental models.

Important aspects of this work included that the researchers created a local community for system dynamics, developed the modeling work as a public good for use by the mental health community, and were client-centred while remaining realistic about limitations. Based on this experience, the authors are optimistic that system dynamics promises to have a major role in designing and evaluating mental health services in the future.

Hyunjung Kim, from the University at Albany, gave a presentation titled Broadening Boundary Perception in a Multi-organizational Context: Study of a Community Mental Health Program in New York State. In her presentation, she reported on an interesting project studying a community mental health care programme aimed at individuals with difficulty living unsupervised in the community (Assisted Outpatient Treatment). She found that there was an important difference in the perceived system boundary on the state and the local implementation level. This difference in the perception of the relevant system boundary can lead to a fundamentally different assessment of the performance of the programme. While the state level perspective focuses on the particular programme in question, local stakeholders are aware of other activities competing for resources and involving the same client group. In the project simulation, models from both perspectives were created and compared.

Including the local level perspective forced the consideration of voluntary participation in the programmes in addition to those who were forced to participate following a court order. Moreover, it also led to the inclusion of the wider group of recipients of mental health services (including those having been mandated or voluntary participants under the particular programme in the past.) The local level perspective also included service providers and the judicial system. Including these additional elements allowed a more accurate understanding of work load and system pressures.

The study concluded that communication between different levels of organizations is essential for the successful implementation of programmes, and that system dynamics can provide a valuable tool in that context. Defining the system boundary broadly from the outset is important in order to collect all relevant data. The setting of the boundary influences the diagnosis of the situation: what might look like a system in balance, seen from the perspective of a too restricted boundary, might be indeed a system under considerable pressure if analysed from a broader, more appropriate perspective. An understanding of the wider system is important as, otherwise, the extent of pressures and constraints in the system is ignored to the detriment of proper planning.

Steffen Bayer

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