Mental health network governance and coordination: Comparative analysis across 10 Canadian regions

by Mary E. Wiktorowicz | Sep 25, 2009

Main Messages

  • Shifting mental health care to the community implies developing a system of coordinated care. Local mental health networks that foster relationships among clinical, addictions, rehabilitation and housing services offer a means to facilitate such coordination.
  • Implementing coordinated care is complex: it involves translating policy into client-related activities mediated by numerous organizations. We found the degree of coordination depended on the extent to which mental health organizations cooperated in a local network.
  • A network executive committee was instrumental in developing a shared vision among its organizations. It also offered a forum for organizations to align their contributions and strategically focus resources in the areas in which evidence revealed the need for service capacity.
  • An alliance governance model fostered cooperation in most small- to mid-size urban and rural local networks; organizations defined their strengths and assigned services accordingly.
  • Metropolitan networks face the greatest challenges in developing an alliance, as achieving a common vision and dialogue among a multitude of organizations is a complex undertaking. Metropolitan networks with an alliance model require greater administrative support to assist organizations in developing a common vision and fostering coordination.
  • Metropolitan networks with a psychiatric hospital experienced challenges in coordinating care, as hospitals offer a range of programs and have less need to connect to their network.
  • Issues of confidentiality could pose obstacles in coordinating services among organizations.
  • Dividing budget and planning authority between the provincial government and network (or regional) governance, respectively, could impede service coordination. Hospitals that reported to the Ministry were not held accountable when their services were not aligned with the mental health organizations in their network. Such divided authority serves individual operating units rather than network and community needs.

Executive Summary

As mental health care shifts to the community, each region and local area must address the challenge of determining how to develop mechanisms of service coordination among its organizations to ensure continuity of care. Operationally, this involves fostering relationships among mental health and primary health care, hospitals, rehabilitation, addiction, housing and related organizations through a local mental health network. Implementation can be complex, as local policies must be translated into client-related activities mediated by numerous organizations to create a network of coordinated services. Developing an organized delivery system implies not only a range of services, but the processes, arrangements and incentives needed to ensure these organizations coordinate their care and are optimally configured.

Our research describes and offers a comparative framework of the governance models and organizational mechanisms mental health networks use to coordinate services, by exploring the organizational processes adopted among them. The research was guided by organizational theory and used qualitative methods of focus groups and interviews with executives and front-line managers in 10 mental health networks across four provinces.

Mental health networks were found to adopt one of three governance models: corporate structure, where an overarching formal authority fosters coordination through control of hospitals and community mental health centres as occurs through a Regional Health Authority (RHA); voluntary mutual adjustment, where pairs of organizations engage in voluntary exchanges (e.g. client referral); and an alliance, where autonomous organizations form a coalition whose relations are more formalized than in mutual adjustment, but in which organizations maintain their autonomy.

An alliance was the predominant model used to coordinate care in the small and mid-size urban networks whose size offers optimal conditions for coordination; developing working relationships is most manageable when a reasonable number of organizations are involved. The ability of the key organizations to identify with one other and understand their collective role in coordinating care also tended to foster a sense of accountability to the network and local population.

Coordination in metropolitans is complex, as developing a common vision and building mutual trust and cooperation among a multitude of organizations is more difficult than in small and mid-sized urban networks with fewer mental health service organizations involved. Inadequate means to share and protect the confidentiality of health records can further hamper service coordination. Small community-based organizations were also not as easily identified within metropolitans and found it difficult to establish working relationships with hospitals. Although three of the four large urban centres in our study relied on mutual adjustment to coordinate services, we found it was a weak model for coordinating care from a systems perspective. Metropolitan networks that sought to establish an alliance also experienced greater challenges, and we found they required additional support. Among the networks studied, those governed through a corporate model of a Regional Health Authority (RHA) with an integrated management structure offered the most support to organizations in achieving unity of effort.

When a psychiatric hospital was present in a network, we found its cooperation was pivotal to achieving coordinated care. While the absence of a psychiatric hospital could limit access to beds, in some cases it could facilitate network planning. First, resources were not embedded in an institutional model, which made it easier for programs to change course. Second, shifting services to the community was not affected by hospital union contracts.

However, integration through a corporate governance model such as an RHA was not the only means to achieve coordination. As the mid-size urban networks’ alliances demonstrated, a committee of program executives achieved consensus on how best to align their programs to address local needs. When service gaps were identified, for example, alliance leaders developed innovative means to address them by cooperatively reallocating financial and human resources. In networks governed by mutual adjustment, an executive forum that could address issues in a responsive manner generally did not exist. An alliance model was also found to be less effective in metropolitans that did not receive sufficient support.

We found the networks that relied on voluntary mutual adjustment were unable to achieve a common vision and system coordination, even though some sub-network partnerships existed. When an alliance or corporate structure mediated coordination, shared understandings and service agreements were fostered. Catalysts of coordination included a network director of mental health services with jurisdiction across the continuum of care, and regional or network-wide committees with representation from hospital and community-based organizations that guided administrative and clinical arrangements among organizations.

Coordination was not as well supported when budget and planning decisions were made at different jurisdictional levels. We found that when budget decisions were made at the provincial level while services were planned at the local network level, the divided authority meant organizations that reported to the Ministry were not held accountable when their services were not aligned with the organizations in their network. Such misalignment was most evident when secondary and tertiary facilities reported to the Ministry, while networks planned local community services. Without a mandate or incentives for hospitals to align their care with community services, delays were experienced in achieving continuity of care; patients who had to navigate their own services were more likely to “fall through the cracks” and re-enter hospital.

When a network was accountable for coordination, its executive committee aligned organizations to develop a vision, as well as strategic and operational plans. Cooperative innovations were developed to address service gaps. Conversely, when accountability for coordination was at the provincial level or diffused ambiguously across provincial/regional/network levels, planning tended to serve individual operating units rather than community needs.