Évaluation du Plan d’action en santé mentale (2005-2015) : intégration et performance des réseaux de services

Cet article présente les résultats d’un programme de recherche visant à : 1) évaluer l’implantation de la réforme en santé mentale (SM) et ses facteurs favorisant ou entravant dans 11 réseaux locaux de services et la performance d’équipe en SM ; 2) cerner dans quatre réseaux les processus influençant la qualité des services d’équipe ; 3) analyser dans ces mêmes réseaux les effets des structures et des processus d’équipe sur les usagers. Les objectifs de la réforme en SM n’ont été que partiellement atteints dans les réseaux. Les résultats montrent qu’une plus grande utilisation d’outils et d’approches cliniques et des interactions fréquentes entre les équipes et les organisations améliorent la performance. De même, divers processus d’équipe comme l’autonomie, la participation aux processus décisionnels et le partage des connaissances incitent à la performance des professionnels et à la qualité des services. L’intensité des besoins des usagers réduit la capacité des services à répondre aux besoins. Enfin, le rétablissement et la qualité de vie sont fortement corrélés à la continuité et à la diversité des services offerts. Différentes recommandations sont formulées afin d’améliorer les services dont la promotion de cultures organisationnelles plus orientées sur les résultats et la collaboration, le soutien et la formation des professionnels sur l’intégration de pratiques basées sur les données probantes, l’augmentation de l’autonomie des professionnels et leur implication dans les décisions, ainsi que la formalisation de stratégies d’intégration. Enfin, un soutien biopsychosocial diversifié et continu d’intensité variable est recommandé pour améliorer le rétablissement et la qualité de vie des usagers.

Objectives This study aimed to: 1) assess implementation of the 2005-2015 Quebec mental health (MH) reform, and its enabling and hindering factors as well as MH team performance, in 11 local health service networks; then, for a subset of 4 networks: 2) identify processes influencing service quality in MH teams, and 3) analyze effects of team structures and processes on outcomes for service users.

Methods The networks were selected in consultation with 20 MH decision makers. Data sources included: 1) documentation on population, organization and service characteristics, integration strategies, and network challenges; 2) individual and group interviews with 102 regional managers, MH professionals and managers from primary care or specialized MH teams, community organization directors, respondent psychiatrists and general practitioners (GPs); and 3) questionnaires completed by 16 respondent psychiatrists, 90 managers, 315 MH professionals from primary care or specialized teams, and 327 service users.

Results Objectives of the MH reform were only partially achieved across the 11 health service networks, given the limited availability of practice guidelines related to implementing new structures and services, and reluctance among MH professionals (mainly GPs) to adopt them. As well, most primary care teams lacked GPs or psychiatrists. Implementation was more successful in large networks with specialized services located in general hospitals. The use of clinical tools and approaches, and frequent interactions with other teams or organizations enhanced team performance. Several team process variables including autonomy, involvement in decision-making, and knowledge sharing were strongly associated with the performance of MH professionals and higher quality services. While geographic variables (e.g. frequency of interactions with GPs) had more influence on performance in specialized services, individual variables (e.g. lower seniority in the team) and organizational variables (e.g. lower proportion of service users with personality disorders) influenced performance in primary care teams. Work satisfaction was more strongly associated with team process variables (e.g. fewer conflicts, higher team support, greater collaboration) and recovery-oriented services with organizational variables (e.g. primary care team). Some types of organizational culture were strongly associated with team performance (clan and hierarchical cultures), and work satisfaction (market culture). Concerning effects of team structure and processes on service user outcomes, higher quality of life and recovery scores were strongly associated with continuity and diversity of services. Finally, high seriousness of needs among service users represented a major obstacle for MH services attempting to address their quality of life issues and recovery.

Conclusion This study suggests various measures that may improve MH service quality: promotion of more results-oriented organizational cultures, and greater collaboration, professional training on evidence-based practices, greater support for professionals, increasing their autonomy and involvement in decision-making, and more formalized integration strategies. Diversified and continuous biopsychosocial support was also recommended for improving quality of life and recovery among service users.