Date Published: June 22, 2018
Publisher: Public Library of Science
Author(s): Aled Jones, Ben Hannigan, Michael Coffey, Alan Simpson, Iratxe Puebla.
In response to political and social factors over the last sixty years mental health systems internationally have endeavoured to transfer the delivery of care from hospitals into community settings. As a result, there has been increased emphasis on the need for better quality care planning and care coordination between hospital services, community services and patients and their informal carers. The aim of this systematic review of international research is to explore which interventions have proved more or less effective in promoting personalized, recovery oriented care planning and coordination for community mental health service users.
A systematic meta-narrative review of research from 1990 to the present was undertaken. From an initial return of 3940 papers a total of 50 research articles fulfilled the inclusion criteria, including research from the UK, Australia and the USA.
Three research traditions are identified consisting of (a) research that evaluates the effects of government policies on the organization, management and delivery of services; (b) evaluations of attempts to improve organizational and service delivery efficiency; (c) service-users and carers experiences of community mental health care coordination and planning and their involvement in research. The review found no seminal papers in terms of high citation rates, or papers that were consistently cited over time. The traditions of research in this topic area have formed reactively in response to frequent and often unpredictable policy changes, rather than proactively as a result of intrinsic academic or intellectual activity. This may explain the absence of seminal literature within the subject field. As a result, the research tradition within this specific area of mental health service delivery has a relatively short history, with no one dominant researcher or researchers, tradition or seminal studies amongst or across the three traditions identified.
The research findings reviewed suggests a gap has existed internationally over several decades between policy aspirations and service level interventions aimed at improving personalised care planning and coordination and the realities of everyday practices and experiences of service users and carers. Substantial barriers to involvement are created through poor information exchange and insufficient opportunities for care negotiation.
Mental disorders have become a leading cause of ill-health and disability globally, a growing trend which shows little or no sign of abatement . The evolution of mental health services internationally to meet this demand has been described as occurring in three periods: the rise of the asylum, the decline of the asylum and the reform of mental health services . In this the third period, governmental reform across several countries has resulted in care delivery being moved away from large institutions into community-based services which are supported by acute hospital-care when needed . Such models of community based mental health care require models of service delivery that provide a patient-centred system of care that is well coordinated across health and social care sectors, professional groups and teams . However, community patients living with multiple health and social care needs often experience a highly fragmented service, leading to sub-optimal care experiences, outcomes and costs . To address these shortcomings, policies internationally have been devised to promote better, more personalized and patient-centred care coordination and care planning, yet evidence suggests that such policy innovations have not achieved their objectives .
A meta-narrative review of the literature looks historically at how particular research traditions have unfolded over time and shaped the kind of questions being asked and the methods used to answer them. As outlined by Greenhalgh et al  a research tradition is a ‘series of linked studies, each building on what has gone before and taking place within a coherent paradigm (that is, within a shared set of assumptions and preferred methodological approach shared by a group of scientists)’. In addition to the principles of pragmatism and pluralism outlined above, the following four guiding principles  were used to guide analysis and synthesis.
Initial searches of the literature were undertaken using the following key words and terms: mental health, care planning, care coordination (and co-ordination), collaborative care, recovery, recovery focus(ed), personali*. A preliminary search of the CINAHL, Medline and PsycINFO databases was undertaken, from which a random sample of 20 articles were assessed by BH and AJ to identify possible additional search terms/phrases. In addition, a data extraction template capturing various aspects of research design such as the study setting, characteristics of the sample, study design (data collection and analysis) and results/findings was piloted at this time and found to be effective.
As already mentioned the MNR was undertaken to inform a recently completed study of community mental health care planning and care coordination in sites across England and Wales. As a result, the overview of the historical context is focussed predominantly on to the UK.
This section will introduce the three traditions of research identified during the iterative process of searching and reviewing the literature. The MNR principle of reflexivity was embedded into the searching and reviewing process, which included continually mapping, appraising and reflecting on research designs and findings with the co-authors. Emergent review findings and research traditions were drafted and re-drafted following discussions within the research team, a process which included presenting two draft sections of the review and emergent/potential research traditions for discussion and feedback from other project stakeholders, via the PAG and the LEAG. Members of the PAG/LEAG also provided useful information about literature which had not been captured by the initial searches. Although none of these additional articles were directly relevant to the review’s inclusion criteria they often provided relevant and interesting information about the context, practitioner and user experiences of care planning. At the conclusion of this iterative process a final total of three research traditions had been identified.
To recap, the aim of meta-narrative reviews is to inspect the range of approaches to studying an issue, interpret and produce an account of the development of these separate ‘meta-narratives’ and then form an overarching metanarrative summary . This process of synthesis may involve seeking commonalities in underlying conceptual and theoretical assumptions and exploring differences in these assumptions. In particular, the principle of contestation encourages reviewers to generate insights from different research traditions about how, for example, different researchers have framed the issue differently or made different assumptions about the nature of reality .
Unlike traditional aggregative reviews of the literature that are often conducted in a series of linear and sequential steps following a priori protocol and concepts, this narrative review involved continual iteration and retracting of steps in an attempt to clarify and explain emergent concepts. The process of iteration has been effective for the purposes of making sense of a highly diverse body of literature from across many areas of research (psychiatry, social sciences, nursing, social work). However, a possible limitation of this approach is that the identification of research traditions and the storylines therein is a process described by previous researchers as ‘irrevocably subjective and negotiable”  (p.427). To mitigate this, we received regular feedback on the process and outcomes of our narrative mapping from both advisory group which collectively consisted of clinicians, managers, service users, policy makers and researchers.
Our review addresses a significant gap within the mental health literature. No review of care planning and coordination in community currently exists, a surprising fact given, as we outline in the opening section, that government policies and service redesigns nationally and internationally have increasingly emphasized the need for improvement and innovation in this area of healthcare practice. For example, in response to political, social and other factors over the last 60 years mental health policy makers internationally have created an expanded mental health system which encompasses the large-scale provision of care to people living in the community. However, as a study commenting on the UK mental health policy context argues , in their zest to secure improvement in a neglected field policymakers have unleashed a surfeit of downwards-directed actions, paid insufficient attention to the need to build strong partnerships across the system as a whole and failed to examine sufficiently the cumulative effects of their activities. Our meta-narrative review of the literature relating to care planning and care coordination in community settings accords with this view, whilst providing insights into the effects of policies on the experiences of care planning and coordination on patients and employees in different national and local health systems.