Réformes dans lorganisation des soins de santé mentale
Authors: Schmitz Olivier , Props Annie , De Jaegere Veerle , Antoine Cindy , Leys Mark 
Published: January 2025

Table of contents -- GLOSSARY .. 4 -- 1 INTRODUCTION .. 5 -- 1.1 THERAPEUTIC PROJECTS: COLLABORATION IN MENTAL HEALTH CARE .. 5 -- 1.1.1 Objectives of this second intermediate report .. 5 -- 1.2 METHODOLOGY, DATA COLLECTION AND ANALYSIS .. 6 -- 1.2.1 Methodology .. 6 -- 1.2.2 Data collection.7 -- 1.2.3 Data analysis.7 -- 1.3 PATIENT DATA .. 7 -- 2 HISTORY OF TP.8 -- 2.1 PREVIOUS COLLABORATIONS BETWEEN PARTNERS.8 -- 2.1.1 Informal collaboration between partners.9 -- 2.1.2 Formal collaborations between partners .. 10 -- 2.2 THE PREPARATION OF THE TP- PLAN.11 -- 2.2.1 The role of MHCCPs and ISHC .. 11 -- 2.2.2 The elaboration of the proposal.12 -- 2.2.3 The selection of the partners .. 14 -- 3 OBJECTIVES OF THE TPS .. 15 -- 3.1 INTRODUCTION.16 -- 3.2 COLLABORATION OBJECTIVES .. 16 -- 3.2.1 Patient and family level .. 16 -- 3.2.2 Partner level.17 -- 3.3 SERVICE DELIVERY OBJECTIVES .. 18 -- 3.3.1 The transition between organisations .. 18 -- 3.3.2 Accessibility of care.19 -- 3.3.3 A better use of care.19 -- 3.4 OUTCOME OBJECTIVES.20 -- 3.4.1 Patient level .. 20 -- 3.4.2 Professional level .. 20 -- 3.5 SPECIFIC CLUSTER-RELATED INFORMATION.20 -- 4 SELECTION OF THE TARGET POPULATION.22 -- 4.1 MOTIVATIONS FOR SELECTION OF PATIENT GROUP .. 22 -- 4.2 INCLUSION AND EXCLUSION CRITERIA .. 23 -- 4.2.1 Inclusion criteria.23 -- 4.2.2 Exclusion criteria .. 24 -- 4.3 CHRONIC AND COMPLEX.25 -- 4.4 CARE PATHWAY.26 -- 5 SELECTION OF THE PARTNERS .. 27 -- 5.1 FORMAL PARTNERS.29 -- 5.1.1 Obligatory partners.29 -- 5.1.2 Non-obligatory partners.30 -- 5.1.3 The role of the formal partners .. 31 -- 5.2 INFORMAL PARTNERS .. 31 -- 5.3 PARTNERS NOT PARTICIPATING IN THE TP.32 -- 6 GEOGRAPHICAL AREA OF ACTIVITY .. 33 -- 6.1 SIZE OF THE CATCHMENT AREA .. 33 -- 6.2 CONTEXT-RELATED FACTORS .. 33 -- 6.3 MOTIVATIONS.34 -- 7 COORDINATION.36 -- -- 7.1 INTRODUCTION.36 -- 7.2 MEETINGS .. 36 -- 7.2.1 Meetings coordinating the partnership activities.36 -- 1.1.1 Patient-related meetings.37 -- 7.2.2 Separate or combined meetings .. 40 -- 7.2.3 Other meetings.40 -- 7.3 THE COORDINATORS.42 -- 7.3.1 The overall coordinator .. 42 -- 7.3.2 The project coordinator.42 -- 7.3.3 The administrative coordinator .. 45 -- 7.3.4 Allocation of coordination tasks.45 -- 7.4 TOOLS.46 -- 7.4.1 Tools used to support operational tasks .. 46 -- 7.4.2 Tools used to support the coordination of administrative tasks.49 -- 8 CURRENT EXPERIENCES.50 -- 8.1 INTRODUCTION.50 -- 8.2 GENERAL APPRECIATION OF THE TP-PROGRAMME.50 -- 8.2.1 Impact of the TP-programme .. 50 -- 8.2.2 Financing model .. 51 -- 8.2.3 The patient monitoring.51 -- 8.2.4 Communication from the public agencies.51 -- 8.2.5 Other (parallel) formal collaboration initiatives .. 51 -- 8.3 EXPERIENCES : PATIENT ISSUES .. 52 -- 8.3.1 Influence of the TP-programme on patients.52 -- 8.3.2 Experiences with the inclusion process.52 -- 8.3.3 Patient and/or family participation .. 54 -- 8.4 EXPERIENCES: PARTNERS .. 56 -- 8.4.1 The required configuration of the partnership .. 56 -- 8.4.2 Managing the partnership.. 57 -- 8.4.3 The involvement of partners.58 -- 8.4.4 Experiences with the inclusion process.59 -- 8.4.5 Experiences with the follow-up process.60 -- 8.4.6 Experience with coordination tools.61 -- 8.5 EXPERIENCES WITH THE COORDINATOR .. 63 -- 8.5.1 The role of the coordinator .. 63 -- 8.5.2 Support for the project coordinator.. 64 -- 8.5.3 Workload of the coordinator.64 -- 8.5.4 Human resources issues.65 -- 9 DISCONTINUING PROJECTS .. 66 -- 9.1 INTRODUCTION.66 -- 9.2 REASONS FOR DISCONTINUING .. 67 -- 9.2.1 The administrative requirements of the TP-programme.67 -- 9.2.2 The commitment of partners .. 68 -- 9.2.3 Role and employment location of the project coordinator .. 68 -- 10 GENERAL DISCUSSION .. 69 -- 10.1 METHODOLOGICAL ISSUES.69 -- 10.2 VARIETY IN PLANS .. 70 -- 10.2.1 One TP-framework, different interpretations.70 -- 10.2.2 Preparation of the TP-proposal .. 71 -- 10.2.3Objectives.71 -- 10.2.4 Partnership level.72 -- 10.2.5 Patient level .. 74 -- 10.2.6 Area of activity.74 -- 10.3 EXPERIENCES .. 76 -- 10.3.1 Promotion of the TP.76 -- 10.3.2 Chronic and complex .. 77 -- 10.3.3 Care plan.77 -- 10.3.4 Coordinator.78 -- 10.3.5 Experience with primary care.. 79 -- 10.4 FUTURE RESEARCH STEPS.81 -- 11 PRELIMINARY LESSONS LEARNED.82 -- 11.1 THE GOVERNMENTS PROGRAMME.82 -- 11.2 THE DESIGN OF THE TP (THE PLANS).83 -- 11.3 COMPLEX INTERAGENCY COLLABORATION .. 83 -- 11.4 COORDINATION .. 84 -- 11.5 THE CARE PLAN .. 84 -- 11.6 THE PATIENTS .. 84 -- 11.7 AREA OF ACTIVITY.85 -- 11.8 INVOLVING PRIMARY CARE PARTNERS .. 85 -- 12 REFERENCES.87