The increasing specialization and differentiation within welfare organizations in Sweden and internationally have, due to fragmentation and inflexible boundaries, resulted in ineffective care for users. In order to improve care, the Coordinated Individual Plan (CIP) was introduced by the government in Sweden in 2009, with the aim of improving collaboration between social service and health care. Persons with concomitant mental health problems and substance abuse were one of the target groups. Earlier studies by the authors indicate that CIP has had limited impact. Use of CIP has been unsystematic and the user/patient’s role less central than expected. This study investigates what can contribute to these findings, based on professionals’ experience of their participation in CIP. Interviews were conducted with 20 professionals in the social service and health care sectors and analysed by qualitative content analysis, using the theoretical perspectives of institutional isomorphism. Findings indicate that, while the professionals were positive about the idea of CIP to improve the situation for the individual user/patient, coercive isomorphism in the form of CIP also led to a more confrontational view of collaboration which does not necessarily solve problems for the individual. Organizational and professional perspectives were cited, which can be linked to issues of organizational uncertainty. The study confirms earlier findings indicating that a stronger, team-based model is needed, with development based on professional experience, as the coercive aspect tends to take precedence over professional activities connected to mimetic and normative isomorphism.

Fragmentation of social service and heath care services has been given attention in many countries and a variety of strategies and models are used in attempts to remedy the problem. In a parallel development, demands have been made that users/patients should have more influence over their own care, and research has shown that user involvement can support the recovery process. This article focuses on how professionals view user involvement in collaborative efforts in care planning, using the Coordinated Individual Plan (CIP) in Sweden as an example.

Since 2009, social service and health care agencies are required to draw up CIPs when they are judged to be needed, with the purpose of improveing the care process. An additional purpose is to increase users' involvement in their own care. Semi-structured interviews were conduced in 2019 with 20 professionals working within social service and health care agencies for people with mental health and/or substance abuse problems in the Stockholm region. Analysis was by qualitative content analysis.

Findings show that professionals experience ambivalence concerning user involvement in care planning. On the one hand, they support the user's own demands of services and on the other hand, they correct the user's demands to fit the range of services and organisation of care. The user/patient's position is expressed as vulnerable, caugh between caregivers who often safeguard their own organisational duties and economical restrictions. These findings reflect the conflict predicted by Lipsky's theory of street-level cureaucracy. Professionals are expected to act as advocates for the user/patient, while at the same time exercising a controlling and gatekeeping function. The question is raised whether a model such as CIP provides sufficiently for factors which can counterbalance the power of the professionals relative to the user/patient in care planning.

Specialisation in care and welfare services often leads to inflexible boundaries between organisations and professions, resulting in fragmented and ineffective care, not least in the areas of severe mental illness and substance abuse. Collaborative models such as case management, multidisciplinary teams and coordinated care plans are used in many countries to address this problem. In a parallel development, demands have been made that individual users/patients should have more influence over their own care. In Sweden, legislation requires the social service and health care to draw up Coordinated Individual Plans (CIP) to clarify responsibility, improve the care process and increase users’ involvement in their own care. This article explores the impact of coordinated care plans, using the Swedish CIP as an example. What can we learn about conditions for integrated care according to the degree of collaboration, involvement for the individual user and supporting structures? The authors have studied 25 case files in a local authority. Findings indicate a low to moderate degree of collaboration and few indications of meaningful user involvement. Further studies are needed concerning factors hindering CIP from achieving a higher degree of collaboration and fully including the intentions and wishes of the individual.

Specialisering och sektorisering i välfärdsservice orsakar svårigheter i många länder, inte minst för vuxna med komplexa behov i samband med missbruk och psykisk ohälsa. Modeller för samverkan, t.ex. case management, multidisciplinära team och individuella samordnade planer, används i många länder i syfte att uppnå en högre grad av integration mellan organisationer. Samtidigt har kraven ökat för att brukare/patienter ska ha större påverkan över sin egen vård. I Sverige kräver lagstiftning att socialtjänst- och hälso- och sjukvårdvårdssektorerna gör Samordnade Individuella Planer (SIP, eng. CIP) kring enskilda brukare i syfte att klargöra frågor om ansvar och förbättra vårdprocesser samt för att öka brukarnas delaktighet i sin egen vård. Denna explorativa studie undersöker vilken påverkan samordnade planer har haft, med den svenska SIPen som exempel. Vad kan vi lära oss om villkoren för integrerad vård utifrån graden av samverkan, delaktighet för brukaren samt stödjande strukturers roll i genomförandet av SIP? Författarna har studerat 25 akter i en kommun. Resultaten visar en låg till måttlig grad av samverkan med få indikationer på meningsfull brukardelaktighet. Ytterligare forskning behövs för att undersöka vilka faktorer som hindrar CIP från att uppnå en högre grad av samverkan och helt omfatta den enskilde brukarens intentioner och önskemål.

Behovet av samverkan kring personer med psykisk ohälsa och/eller missbruk har en förhistoria som handlar om utanförskap i den framväxande välfärden i Sverige. I detta kapitel, som inleds med en tillbakablick, följer vi förändringarna fram till idag, beskriver vad forskning har att säga om möjligheterna och hiner med olika samverkansmodeller och frågar oss hur en fungerande modell för samverkan kan formas utifrån aktuella förutsättningar.

 In conjunction with the dismantling of psychiatric hospitals, social workers have been commissioned to help service users in their daily living in their homes and in the community. The consequences of these changes for experience-based knowledge and practices in their contexts remain relatively unknown. In this study, eighteen service users and the social workers they described as helpful for them were interviewed. The interviews were recorded, transcribed, and analyzed using Thematic Analysis. The following themes emerged: “Here, there and everywhere”, “Doing, being, becoming”, “Talking” and “Order, planning and improvisation” concerning the contradictions service users and professionals mentioned about their practices and the conditions imposed by managerial methods connected to New Public Management. Finally, “Spontaneous planned complexity” was chosen as our overarching theme to characterize the new knowledge and practices which have been developed. The displacement of the place for the encounter and the introduction of non-medicalized professions have allowed community-based practices and thus the co-creation and emergence of new knowledge about the service users as persons and the professionals as qualified professionals. The challenge remains for managers to have trust in their colleagues and not impose rigid rules, schematized methods, and repeated controls. 

Background:

User involvement, based on respect and carried out through dialogue, has been shown to lead to increased self-respect, self-confidence and positive identity. In Sweden, the Social Service Act requires that interventions be designed and implemented together with the individual concerned. The basic criterion for social support is prolonged severe mental illness (usually at least 6 months), with no criteria for specific diagnosis or institutional history. The most common form of social support is ‘support in daily living’, a community care intervention for people aged 18 years or older who have their own homes and living arrangements.

Aim:

This article aims to deepen our understanding of user involvement at the individual level in the provision of an ongoing social work intervention. What elements of user involvement can be found in users’ and support workers’ descriptions of helpful support in daily living?

Method:

Qualitative interviews were conducted with 18 users, who had experienced support in daily living as helpful, and 16 interviews with the users’ support workers.

Results:

Three major, interconnected themes emerged: Constant dialogue; Framing the flexibility, in relation to formalized intervention plans and regulations; The importance of ‘small things’, decisions concerning daily life.

Conclusion:

Both users and support workers described user involvement at the individual, micro-level to be an integral part of helpful support in daily living. It was possible to create a space for dialogue and co-creation in which users were involved in formulating and deciding the contents of their support at an informal level, to influence their own everyday lives. While a formal framework of rules, restrictions and plans surrounds meetings between users and professionals, a facilitating factor may be the absence of too detailed plans and regulations, leaving trust to users and professionals and their capacity to manage most of the choices they have to make.

Evidence-based method or practical support for users? Supported Employment without IPS

Since the Mental Health Reform of 1995, the social service in Sweden is required to offer ”meaningful activities” to persons with mental health impairments. This requirement has usually been met by the social service’s ”daily activities” centres, which do not have contact with the competitive labour market. ”Supported Employment” (SE) is a method which can be used to help people with mental health, neuropsychiatric or intellectual impairments to regular work places. Based on international research, the SE model ”Individual Placement and Support” (IPS) is recommended in national guidelines as an evidence-based method. However, IPS can be difficult to implement, since the model requires integrated teams, while in the Swedish system health care, social service and vocational rehabilitation belong to different sectors. Another reason is that subsidized forms of employment and internship are more usual in Sweden than in many other countries. This study investigates SE practices in three municipalities which do not follow all of the IPS model’s eight ”basic principles”. The results show that after 18 months many persons who had been totally without regular activities, or had access only to a daily activities centre, had some form of work or internship at regular workplaces. Twenty per cent had paid employment. The author interprets IPS as a ”packaging” of SE which the municipalities have ”translated” locally to offer SE activities which benefit users. This can also be seen as evidence-based practice (EBP), in which the best available research has been combined with the wishes of users and the professionals’ judgement of what is possible to offer in practice. Further research is needed concerning the value for users of prolonged internships which do not lead to paid employment.

Socialtjänsten ska enligt SoL erbjuda "meningsfull sysselsättning" till personer med psykisk funktionsnedsättning. Insatserna har dock i huvudsak under lång tid varit begränsade till verksamheter utan koppling till ordinarie arbetsmarknad, s.k. "daglig verksamhet". "Supported Employment" (SE) är en metod för att i stället hjälpa personer med psykisk funktionsnedsättning, samt även personer med neuropsykiatrisk funktionsnedsättning eller utvecklingsstörning, att hitta sysselsättning på ordinarie arbetsplatser. Modellen "Individual Placement and Support" (IPS) har framhållits av Socialstyrelsen i nationella riktlinjer, framför allt utifrån internationell forskning. Svensk forskning har dock visat på svårig-heter med att implementera IPS, dels därför att IPS förutsätter integrerade ar-betsteam med psykiatrin, dels på grund av den stora förekomsten av subvention-erade sysselsättningsformer som praktik och lönebidrag. I denna studie under-söks SE-verksamheter i tre kommuner som inte uppfyller samtliga de åtta grundprinciperna som ställts upp för IPS. Resultaten visar att efter 18 månader hade många personer som tidigare helt saknat sysselsättning, eller som endast haft "daglig verksamhet", kunnat få sysselsättning i någon form och omfattning på ordinarie arbetsplatser. 20 % hade fått löneanställning, ofta på deltid och med lönebidrag. Författaren framhåller att IPS bör betraktas som en "förpackning" av den ursprungliga idén SE. De studerade kommunerna har olika förhållningssätt till IPS, men alla har låtit sig inspireras av SE och har skapat egna verksamheter till gagn för brukarna. Dessa lokalt anpassade verksamheter kan analyseras som lokala "översättningar" och kan även betraktas som en form av evidensbaserad praktik (EBP), där den bästa tillgängliga forskningen har kombinerats med bru-karnas önskemål och de professionellas bedömning av vad som är praktiskt att genomföra. Denna studie visar således att IPS-modellen kan översättas och an-passas till lokal SE-verksamhet, med goda resultat för brukarna. Ytterligare forskning behövs dock, framför allt kring nyttan för brukarna av praktik som inte leder till anställning.

Persons with mental health problems and substance abuse often have complex needs requiring many kinds of help concurrently. In Sweden, an attempt has been made to counterbalance the effects of fragmentation by means of legislation on collaboration, requiring on the individual level the use of Coordinated Individual Plans (Sw. Samordnad Individuell Plan, SIP). The aim of the study is to explore collaboration as it is indicated in SIP and other case documentation with focus on how SIP is motivated, and what kind and degree of collaboration is indicated by the documentation. 12 individual case files have been studied in six local authorities and the results have been analyzed in relation to a regional collaboration agreement and local collaboration agreements. The results show unclear motivation for SIP and that SIP is primarily used for documentation of short-term planning. Use of SIP and participation in SIP appears also to be uneven. The authors characterize SIP as an unsystematic form of interagency meeting, with documentation indicating a relatively low to moderate level of collaboration. The authors question whether SIP is an optimal form for collaboration and suggest that more distinct models such as case management or multidisciplinary teams could be more effective.