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  • 1.
    Bejerholm, Ulrika
    et al.
    Lunds universitet, Institutionen för hälsovetenskaper.
    Markström, Urban
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Bergmark, Magnus
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Svensson, Bengt
    Lunds universitet, Institutionen för hälsovetenskaper.
    From national incentives of implementing Individual Placement and Support to the impact on the service users' quality of life, and view on support2015In: Closing the gap between research and policy in mental health: ENMESH 2015 : Eleventh International Conference of the European Network For Mental Health Service Research : Book of Abstracts, ENMESH , 2015Conference paper (Refereed)
  • 2.
    Bergmark, Magnus
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Integrerade psykosociala insatser: Policy, implementering och praktik i ett komplext verksamhetsfält2017Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Introduction

    Since the deinstitutionalization of psychiatry started in the 1980’s, the field of psychiatry has moved in the direction of community-based psychosocial interventions for people with mental illnesses. The interventions selected should be based on knowledge and evidence, and support the users’ empowerment and recovery. In addition, some of the services should be provided in forms of integrated models, meaning that all agencies involved should provide cohesive care and support. Two examples of such interventions are the occupational rehabilitation program Individual Placement and Support (IPS) and the intensive case management model Assertive Community Treatment (ACT). Although Sweden is considered a high-resource country, the availability of psychosocial services has been criticized. This criticism has been related to policymaking as well as the quality of the services provided. Examples of areas considered problematic include collaboration deficiencies among disparate human service organizations and substantial local variations in available types of services. This thesis aims to examine how national-level policymakers in Sweden have handled the development of psychosocial support and to analyze facilitators and barriers experienced by these organizations in their implementation of community-based and integrated models. The research questions are as follows:

    -       How have policies concerning community-based psychosocial interventions been formulated and how do the characteristics of these policies affect the implementation of its goals?

    -       How do different types of steering strategies influence national-level policy implementation proposals?

    -       Which facilitators and barriers to effective implementation of proposed integrated interventions can be identified?

    -       How can the ability to provide integrated psychosocial interventions be explained in terms of local conditions and strategies used for implementation?

    Methods

    A study of community mental health policy covering three of the major documents published at the national level from the last 20 years was performed. Directed content analysis based on literature relevant for the research area was used. In order to study the implementation of the selected interventions, 15 programs were followed for a three-year period. 14 of these programs were implementing IPS and the other one implemented ACT. In order to monitor the programs’ adherence to the selected models, program fidelity assessments were performed. Data on the programs’ target groups were collected. Three of the IPS-programs participated in an in-depth study where qualitative interviews with leaders, staff, and collaboration partners were performed. The implementation of the three programs were analyzed utilizing the Consolidated Framework for Implementation Research. All of the 14 IPS programs were included in an implementation study where the Sustainable Implementation Scale (SIS) was used to identify facilitators and barriers to implementation. In the study of the ACT team, qualitative directed content analysis of in-depth interviews and SIS-assessments were performed. After three years, the sustainability of all programs was assessed.

    Results

    Mental health policies have involved high levels of ambiguity and conflict in relation to both the goals and the means. The government has prioritized soft steering strategies, usually in the form of financial stimulus grants. Over time, these policies have (at least to some degree) been clearer when psychosocial interventions are being described. In addition, the development of policy has led to harder steering strategies, illustrated by targeted and performance-based grants and the advocacy of national guidelines to steer agencies towards preferred interventions. Despite these changes, independent agencies are still responsible for selection, framing, and implementation of the interventions.

    Implementation of the integrated models IPS and ACT is possible, even in the context of a sectored welfare system such as Sweden.  However, there are a number of implementation barriers at the organizational and team levels. Obstructive factions include involved agencies disparate traditions and regulations, as well as the programs’ difficulties in securing long-term funding. Some of the staff interviewed considered the characteristics of the interventions as problematic since they challenged existing routines and views about support of the target group. Another critical component was the ability to establish collaboration, both horizontally (with partners at the same hierarchical level), and vertically (between management and staff). A team leader with the mandate to influence interactions horizontally and vertically is therefore a facilitating factor. In most of the programs that managed to perform a sustainable implementation of the models, a critical success factor was found to be staffs’ ability to navigate around a variety of barriers. Additional facilitators to successful implementation was careful planning before the start-up of a program, effective staff recruitment, the formation of a dedicated steering group, and a plan for local funding early in the implementation process. Regularly-performed program fidelity assessments were also noted as an important means to identify improvement opportunities for the programs. Collectively, these components served as tools to increase the programs’ legitimacy since the team leaders used them to provide feedback to the local decision makers.

    Conclusions

    At an abstract level, there is general agreement of the overarching needs in the area of integrated psychosocial interventions, but there are discrepancies when it comes to how to best convert this shared definition of need into concrete psychosocial interventions. The majority of steering strategies used are still considered ‘soft’, which leaves much of the responsibility to the implementing agencies.  At a grass-root level this leads to several difficulties, including unclear responsibility definitions and collaboration challenges between agencies. Instead of prioritizing the work with their clients, the staff are forced to put a lot of time and energy into solving these problems.

    In most cases, team leaders and staff are able to reach high program fidelity at a team level. However, a sustainable implementation demands that a program has been anchored both vertically and horizontally. There is a need for a holistic approach by researchers and decision makers, both in the area of policymaking and implementation of selected psychosocial interventions. Assessments of program fidelity and implementation have the potential to help agencies identify strengths and opportunities for growth both within each entity and between involved organizations. In order to implement the selected models successfully at an organizational level, the programs´ vertical legitimacy has to increase, and plans for long-term local funding strategies have to be initiated early in the implementation process.

  • 3.
    Bergmark, Magnus
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Bejerholm, Ulrika
    Markström, Urban
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Critical Components in Implementing Evidence-based Practice: A Multiple Case Study of Individual Placement and Support for People with Psychiatric Disabilities2018In: Social Policy & Administration, ISSN 0144-5596, E-ISSN 1467-9515, Vol. 52, no 3, p. 790-808Article in journal (Refereed)
    Abstract [en]

    When developing Community Mental Health Services to support people with psychiatric disabilities, European countries are advocating evidence-based practice (EBP). Individual Placement and Support (IPS) is an evidence-based model designed to support people in acquiring and maintaining competitive employment. Implementation science is a growing research field, with a focus on components that impact the process of implementing EBP programmes. In this multiple case study, we have followed three IPS demonstration sites for two years, in order to describe and analyze barriers and facilitators for implementation, according to constructs described in the Consolidated Framework for Implementation Research (Damschroder et al. 2009). The results highlight the importance of strategic networking, as well as the need for planning and preparations carried out before the start of an EBP programme, since deficiencies related to these constructs are difficult to compensate for.

  • 4.
    Bergmark, Magnus
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Bejerholm, Ulrika
    Lunds universitet, Institutionen för hälsovetenskaper.
    Markström, Urban
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Implementation of evidence-based interventions: analyzing critical components for sustainability in community mental health services2019In: Social Work in Mental Health, ISSN 1533-2985, E-ISSN 1533-2993, Vol. 17, no 2, p. 129-148Article in journal (Refereed)
    Abstract [en]

    This study analyses the implementation and sustainability of evidence-based community mental health services in the form of publicly financed Individual Placement and Support programs. Critical implementation components and program fidelity were assessed after one year. After two years, program fidelity was assessed once again. After three years, the programs’ sustainability was assessed and semi-structured interviews performed, in order to deepen the understanding of implementation. Interviews and documents provided the quantitative and qualitative data, which were analyzed by the use of the Supported Employment Fidelity Scale, the Sustainable Implementation Scale (which was developed in a connecting study), and qualitative content analysis. Despite promising fidelity results after one year, eight out of 14 programs were terminated within three years. Implementation of integrated evidence-based programs in community-based settings is a delicate undertaking. Implementing agencies can benefit from rigorous preparation before program start, especially concerning the circumstances at the organizational level, such as making plans for collaboration, financing and assessments of program fidelity.

  • 5.
    Bergmark, Magnus
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Bejerholm, Ulrika
    Lunds universitet, Institutionen för hälsovetenskaper..
    Markström, Urban
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Policy Changes in Community Mental Health: Interventions and Strategies Used in Sweden over 20 Years2017In: Social Policy & Administration, ISSN 0144-5596, E-ISSN 1467-9515, Vol. 51, no 1, p. 95-113Article in journal (Refereed)
    Abstract [en]

    The deinstitutionalization of mental health care has changed the responsibilities of involved authoritiesand has led to a continuous need for new treatment forms and interventions. This articledescribes this development in Europe, and in particular how these new conditions have been handledin Sweden over the past 20 years at the level of governmental policy-making. Three major policydocuments from 1994, 2009 and 2012 were included in this study. To increase our understandingof the policies’ contents, we have used theoretical concepts concerning governance,implementation and political risk management. Although our main interest was to find out howthe government handles interventions for users of the mental health care system, we found that thepolicy work is progressing stepwise. The first document, from the deinstitutionalization era, did notdiscuss interventions clearly. Instead, it was mainly concerned with both practical and economicalareas of responsibility. The second document, from the post-deinstitutionalization era, was morefocused on what services should be delivered to the users, while the most recently published documentto a greater extent addressed the question of how the support is supposed to be designed. The trendin European community mental health policy has been to advocate services in open forms that areintegrated into the society’s other care systems. This is also the case in Sweden, and continuous workis being done by the government to find strategies to support the development, and to meet the needs atboth political and local levels.

  • 6.
    Bergmark, Magnus
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Bejerholm, Ulrika
    Lunds universitet, Institutionen för hälsovetenskaper..
    Markström, Urban
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Svensson, Bengt
    Lunds universitet, Institutionen för hälsovetenskaper..
    Incorporation of evidence-based programs in local contexts: Components of importance for implementation, fidelity and sustainability.2015Conference paper (Refereed)
    Abstract [en]

    The trend toward evidence-based practice has lead to an increased use of internationally tested programs. This development has been questioned because of translation problems, including the lack of fit with national welfare systems and local organizations. This study has followed the implementation process of 14 Individual Placement and Support (IPS) programs that have received national stimulus startup grants.

     

    The overarching aim was to explore whether a high fidelity implementation of IPS in a real life Swedish context is possible. The study’s focus was directed towards implementation components at different organizational levels, program fidelity, and the sustainability of the initiatives.

     

    Fourteen IPS programs that started during 2012 were selected. Based on research findings that described essential implementation components, an interview protocol and an analysis scale were developed and used. The Sustainable Implementation Scale (SIS) includes components at organizational level, team level, and continuous support. Representatives from the IPS programs were interviewed at baseline, after 12 and 24 months. The 24-month follow-up was conducted 6 months after the disbursement of stimulus grants had ended; therefore questions about the programs sustainability were included. The Supported Employment Fidelity Scale (SEFS) was used to monitor program fidelity after 12 and 24 months.

     

    Five of the municipalities with IPS programs had shut them down, while 3 municipalities had partly integrated IPS in regular programs.

    Six of the programs were fully integrated in the organizations’ regular activities. These 6 programs were characterized by high scores in SIS, primarily on the components concerning recruitment of staff, management, education and access to support structures. There was a significant correlation between the scores on SEFS, SIS, and the sustainability of the program. Collaboration between authorities was a challenge for the programs. An engaged, joint steering group and strategies for local financing were important for the survival of the initiatives.

     

    A high fidelity, real-life implementation of IPS in Sweden is possible, but requires a strong focus on essential implementation components and strategies that address contextual barriers. The SIS is a promising tool for monitoring implementation.

  • 7.
    Bergmark, Magnus
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Bejerholm, Ulrika
    Lunds universitet, Institutionen för hälsovetenskaper..
    Svensson, Bengt
    Lunds universitet, Institutionen för hälsovetenskaper..
    Markström, Urban
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Complex Interventions and Interorganisational Relationships: Examining Core Implementation Components of Assertive Community Treatment2018In: International Journal of Integrated Care, ISSN 1568-4156, E-ISSN 1568-4156, Vol. 18, no 4, p. 1-11Article in journal (Other academic)
    Abstract [en]

    Introduction: There is increasing interest in implementing evidence-based integrated models of care in community-based mental health service systems. Assertive Community Treatment (ACT) is seen as an attractive, and at the same time challenging, model to implement in sectored service settings. This study investigates the implementation process of such an initiative.

    Methods: Interviews were conducted with ACT team members, the process leader, steering group members, and collaboration partners. The “Sustainable Implementation Scale” helped to identify critical implementation components, and these were further explored using the qualitative interview data. The “Tool for Measuring Assertive Community Treatment” addressed programme fidelity, and the initiative’s sustainability was assessed.

    Results: High-fidelity implementation of ACT in a sectored service setting is possible. Prominent components that facilitated implementation were careful preparations, team members’ characteristics, and efforts by the process leader and the steering group to improve networking. Implementation was hampered by conflicting goals among the involved authorities and a mismatch between the ACT model’s characteristics and existing organisational traditions and regulations.

    Discussion and Conclusions: Reducing the uncertainty caused by conflicting goals is an important step in improving the implementation of ACT. In order to facilitate implementation, the goals, regulations, and availability of resources should be aligned horizontally and vertically through the involved organisations.

  • 8.
    Bergmark, Magnus
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Bejerholm, Ulrika
    Lunds universitet, Institutionen för hälsovetenskaper..
    Svensson, Bengt
    Lunds Universitet.
    Markström, Urban
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Facilitators and Barriers for Sustainable Implementation of Integrated Support in a Sectored Community Mental Health Service System: Experiences from a Swedish Project.2017Conference paper (Other academic)
    Abstract [en]

    Aim

    The present research project, reported in several published articles, have studied the implementation of integrated support models (IPS and ACT). Implementation strategies used at several levels have been analyzed, including the national political level, organizational level and team level. This presentation aims to discuss the main findings of barriers and facilitators for sustainable implementation of these interventions in a sectored community mental health service system.

     

    Method

    Qualitative content analysis was used to analyze political steering strategies.

    The Sustainable Implementation Scale, based on findings from implementation science, was used to assess effectiveness of implementation.

    The Supported Employment Fidelity Scale and Tool for Assessment of Assertive Community Treatment was used to assess program fidelity of 15 programs.

    Data of the selected programs’ target groups and sustainability was used in order to assess the programs establishment in the welfare system’s regular services.

     

    Results

    Sustainable implementation of the selected models is possible, but several barriers in and between different organizational levels exist. Preparations and collaboration strategies are crucial for teams and organizations. The system level includes several inconsistencies that hamper effective implementation.

     

    Conclusions

    Political steering, involved agencies’ organizations and the models supposed to be implemented has to be better aligned. A more holistic approach is needed in order to promote supportive horizontal and vertical inter-organizational relationships.

  • 9.
    Markström, Urban
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Bejerholm, Ulrika
    Lunds universitet.
    Svensson, Bengt
    Lunds universitet.
    Bergmark, Magnus
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Implementeringen av nationella riktlinjer för psykosociala insatser vid schizofreni: exemplen IPS och ACT2015Report (Other academic)
    Abstract [sv]

    Rapporten baseras på ett uppdrag från Socialstyrelsen att undersöka implementeringen av de nationella rikt- linjerna för psykosociala insatser för personer med schizofreni. För att göra frågan mer greppbar valdes två av de insatser som beskrivs i riktlinjerna ut, Individual Placement and Support (IPS) och Assertive Community Treatment (ACT). Urvalet gjordes utifrån angelägenhetsgrad och modellernas kännetecken. IPS är en modell för att stödja personer med psykisk funktionsnedsättning till lönearbete, genom ett individuellt anpassat stöd som sker integrerat med den psykiatriska behandlingen och direkt på reella arbetsplatser utan föregående träning. ACT är en uppsökande, intensiv och integrerad vård- och stödform riktad till personer med mycket stora och komplexa behov, där ett tvärprofessionellt team arbetar med hög tillgänglighet och ansvar för en rad olika insatser som samordnas och erbjuds inom teamet. Båda modellerna är utvecklade i Nordamerika och internationellt väletablerade med stark forskningsförankring. I riktlinjerna utmärks de båda av att erhålla prioritet 1, d.v.s. högsta möjliga angelägenhetsgrad. Modellerna utmärks vidare av en integrerad ansats. Både IPS och ACT innebär att samtidigt ge behandlingsinsatser och socialt och arbetslivsinriktat stöd genom en sammanhållen organisation. Det övergripande syftet har varit att undersöka i vilken omfattning och med vilka resultat som ACT och IPS kan implementeras i en svensk välfärdskontext, samt vilka omständigheter som haft betydelse för process och resultat. Av särskilt intresse har varit frågor om vilka implementationsfaktorer som har betydelse, vad som kännetecknar den svenska tillämpningen i förhållande till originalmodellerna, i vilken utsträckning de lokala försöken har omfattat den grupp av människor som modellerna utformats för och vilka förändringar som kan identifieras hos de individer som fått insatser. IPS studerades genom att följa 14 försöksverksamheter som fått ekonomiskt stöd från Socialstyrelsen för att utveckla metoden. Här genomfördes intervjuer med nyckelpersoner och programtrohetsskattningar vid två tillfällen samt en individuppföljning där information samlades in fortlöpande. Därutöver genomfördes en fördjupningsstudie på tre orter. ACT studerades genom en fallstudie av en försöksverksamhet, där processen följdes över tid genom upprepade intervjuserier och programtrohetsskattningar samt genom en individuppföljning bestående både av intervjuer och information från socialtjänst- och sjukvårdsregister. Implementationsprocessen analyserades genom en modell som inkluderade faktorer på system-, organisations- och utförarnivå samt aspekter som rör fortlöpande stöd.

  • 10.
    Markström, Urban
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Svensson, Bengt
    Lunds universitet, Institutionen för hälsovetenskaper.
    Bergmark, Magnus
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Is ACT possible to implement in a highly sectorized system? A longitudinal analysis of outcomes and critical implementation components in a Nordic case.2015Conference paper (Other academic)
  • 11.
    Markström, Urban
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Svensson, Bengt
    Department of Health Sciences, Lund University, Lund, Sweden.
    Bergmark, Magnus
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Hansson, Lars
    Department of Health Sciences, Lund University, Lund, Sweden.
    Bejerholm, Ulrika
    Department of Health Sciences, Lund University, Lund, Sweden.
    What influences a sustainable implementation of evidence-based interventions in community mental health services?: development and pilot testing of a tool for mapping core components2018In: Journal of Mental Health, ISSN 0963-8237, E-ISSN 1360-0567, p. 395-401Article in journal (Refereed)
    Abstract [en]

    Background: An important aspect of research regarding the implementation of evidence-based practice is the sustainability and long-term stability of a programme. There is a need to measure these critical components for establishing successful programmes.

    Aim: The aim was to develop and pilot test the sustainable implementation scale (SIS) for measuring the critical components in the sustainable implementation of community mental health services.

    Method: The scale was based on implementation research and consisted of three subscales regarding (1) the organisational level, (2) the team level and (3) continuous support. Data from interviews and documents were collected from 14 programmes implementing the Individual Placement and Support model of supported employment.

    Results: Internal consistency was acceptable for all subscales and for the scale as a whole. Regarding the scale, an analysis of the differences between fully established programmes and the programmes that were not established or were or only partially established after three years showed statistically significant differences, indicating that a greater number of implementation components were present in the fully established programmes.

    Conclusions: SIS showed both good reliability and acceptable internal consistency as well as the ability to predict programme survival.

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