The Atlas of Mental Health Care project: International development and applicability for DSS

Prof Luis Salvador-Carulla [email protected]

Prof Carlos Garcia-Alonso [email protected] NEW LINKS BETWEEN ORGANISATIONAL/BUSINESS RESEARCH AND HEALTH CARE RESEARCH (IHI)

Four Questions of leadership, quality and efficiency

Do you know how good you are? Do you know where you stand relative to the best? Do you know where the variation exists? Do you know the rate of improvement over time?

HEALTH ECOSYSTEMS (Nimo et al, Cascadia, 2016) Complex health systems: TOOLS & ANALYTICAL TECH.

Health ecosystems Agents Systems, subsystems, LOCAL ATLAS OF CARE Consumers nested systems Pofessionals, Boundaries and Teams, Availability Population determinants Jurisdictions Organisations Context analysis Capacity GIS Use DSS Logic models Interventions Conceptual maps Packages Financial Flows Social Networks

Frameworks Connections & Drivers CONCEPTUAL MAPS Networks interactions Values, goals, SOCIAL NETWORK ANALYSIS targets Complex health systems: DECISION SUPPORT SYSTEMS

Context Analysis New Procedures LOCAL ATLAS OF CARE MACRO Knowledge Discovery from Data MESO (KDD) MICRO Availability Expert-based Collaborative Jurisdictions Analysis (EbCA) Context analysis Capacity GIS Use DSS Interventions Framing Logic models New Tools Conceptual maps Packages Scientific Visualisation Financial Flows Social Networks Knowledge Simulation Modelling Data mining (experts) CONCEPTUAL MAPS Health ontology Social Network Analysis Research Synthesis SOCIAL NETWORK ANALYSIS Neuronal Network Analysis Conceptual analysis Cluster based on Rules Monte Carlo DEA

Context analysis & Systems thinking

Evidence

Context Implementation From EBM to System thinking : The Greek Temple Salvador-Carulla et al, Epid Psych Sciences, 2016

Scientific Knowledge Evidence- data Mixed Qualitative info

.

tacit

Carers Cohort , , - Knowl

RCTs Context demographics Experiential Experimental Observational Formal and Formal Expert Ecological Consumers GIS,

DISCOVERY -- CORROBORATION -- IMPLEMENTATION

Decision support system

Methodologies: operational, statistical and artificial intelligence

Spatial analysis (statistics) Geographical information systems (statistics)

Relative technical efficiency assessment (operations) Simulation engines (statistics) Variable values interpretation (Artificial Intelligence)

Main Type of Care: Main branches

LONG TERM CARE ACESSIBILITY: access to care

INFORMATION FOR CARE ACCESIBILITY TO CARE SELF-HELP AND VOLUNTARY OUTPATIENT CARE DAY CARE RESIDENTIAL CARE CARE WITHOUT direct provision of care related to needs (e.g. access to GUIDANCE AND ASSESSMENT COMMUNICATION NON-PROFESSIONAL STAFF ACUTE ACUTE ACUTE employment)

PROFESSIONAL STAFF INFORMATION PERSONAL ACCOMPANIMENT HOME & MOBILE EPISODIC 24 HOURS PHYSICIAN COVER OUTPATIENT: contact with the CASE COORDINATION NON MOBILE CONTINUOS NON 24H PHYSICIAN COVER person in a limited period of time NON ACUTE NON ACUTE NON ACUTE PHYSICAL MOBILITY (Continuing care) (Programmed Availability) (eg. visit with the GP).

OTHER ACCESSIBILITY CARE HOME & MOBILE WORK 24H PHYSICIAN COVER

NON MOBILE WORK RELATED ACTIVITIES NON 24H PHYSICIAN COVER DAY CARE: the person spends

NON-WORK STRUCTURED CARE OTHER RESIDENTIAL the day at the facility (e.g. day

NON STRUCTURED CARE hospital or social club)

91 different codes- taxonomy tree RESIDENTIAL: the person sleeps at the facility (eg. acute unit -hostel)

INFORMATION: guidance/ assessment/ SELF CARE/VOLUNTARY: non-paid information WITHOUT follow up (e.g. information about availability of services) staff (e.g. Alcoholic anonymous)

LONG TERM CARE

INFORMATION FOR CARE ACCESIBILITY TO CARE SELF-HELP AND VOLUNTARY OUTPATIENT CARE DAY CARE RESIDENTIAL CARE CARE

GUIDANCE AND ASSESSMENT COMMUNICATION NON-PROFESSIONAL STAFF ACUTE ACUTE ACUTE STEP 2 PROFESSIONAL STAFF INFORMATION PERSONAL ACCOMPANIMENT HOME & MOBILE EPISODIC 24 HOURS PHYSICIAN COVER

CASE COORDINATION NON MOBILE CONTINUOS NON 24H PHYSICIAN COVER

NON ACUTE NON ACUTE NON ACUTE PHYSICAL MOBILITY (Continuing care) (Programmed Availability)

OTHER ACCESSIBILITY CARE HOME & MOBILE WORK 24H PHYSICIAN COVER

NON MOBILE WORK RELATED ACTIVITIES NON 24H PHYSICIAN COVER

NON-WORK STRUCTURED CARE OTHER RESIDENTIAL

NON STRUCTURED CARE

STEP 3 STEP 4 INTEGRATED ATLASES OF MENTAL HEALTH CARE:

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Full Survey

Mixed

Automated

http://cmhr.anu.edu.au/research/projects/atlas-mental-health-care

15 Add slide of history

16

17

18

Mapping of MH Care in Montreal (Lessage et al 2002)

http://cmhr.anu.edu.au/research/projects/atlas-mental-health-care

RURAL

URBAN

Pattern of availability of MTCs for adults> 17 years with lived experience of mental illness. Comparison between CHN and Helsinkin and Uusimaa. Needs profile of WSPIR participants at entry

Daytime activities

Psychological distress

Company

Physical health

Accomodation

Employment & volunteering

Psychotic symptoms

Looking after the home

Information on condition & treatment

Money

Food

Intimate relationships

Safety to self

Other services

Self-Care

Benefits

Basic education

Childcare

Transport

Sexual expression

Drugs

Alcohol

Telephone

Safety to others

Cultural & spiritual

0% 10% 20% 30% 40% 50% 60% 70%

Consumer rated unmet need (n=487) SF rated unmet need (n=559)

REsearch on the FINancial Systems’ Effect on the Quality of MENTal Health Care

REMAST: Local Atlases (mapping) FINCENTO: Financing REQUALIT: Quality of care REPATO: Pathways of care Glossary of Terms Ruiz et al, Epid & Psych Sciences 2017 Refiniment: Quality indicators in 7 local areas of EU Countries

33 REFINEMENT: POLICY AND PLANNING IMPACT OF THE STUDY

Girona • key to reactivate the funding for mental health care • Strengthen mental health management • Development of an integrated, community-oriented MHS SPAIN • Info from Remast + Requalit benchmark area in Spain

• Two psychiatric hospitals redesigned to provide specialized care with psychiatrists on-site 24 hours • Acute residential care for mental disorders provided in FINLAND small acute units located at general hospitals, supported by community care teams • Three psychiatric hospitals were closed

Helsinki 34

HEALTH ECOSYSTEMS: Atlas of MH for DSS: (Catalonia, Basque Country)

• 1.- Atlas of Mental Health (context, service availability, capacity, diversity) - Salvador-Carulla et al, 2002, 2006, 2010; Fernandez et al 2015)

• 2.- Service utilisation - Ferrer M, et al, 2015

• 3.- Cost of Illness - Salvador-Carulla et al, 2011

• 4. Financing (Financing of Illness) - Salvador -Carulla et al, 2010

• 5.- Spatial analysis (hot and cold-spots) - Rodero-Cosano ML et al, 2016

• 6- Smart and relational indicators - Salvador-Carulla L, Salinas-Pérez JA, et al, 2010

• 7.- Technical efficiency analysis - Torres-Jimenez et al, 2016

• 8.- Analysis of management interventions (micro meso y macro management) - Garcia-Alonso et al, submitted

• LOCAL ATLASES OF MH CARE: http://cmhr.anu.edu.au/research/projects/atlas-mental-health-care • MAPPING OF SERVICES IN EUROPE: http://www.refinementproject.eu/ • DESDE-LTC (Tool for Coding and Mapping): http://www.edesdeproject.eu/

EVOLUTION OF MH CARE DELIVERY IN CATALONIA (2002 – 2006 - 2010) Patterns of workforce capacity

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MENTAL HEALTH CARE IN THE BASQUE COUNTRY

Data Area Name Data Area Name B1 Ajuriaguerra G20 Alto Deba-Arrasate B2 G21 Amara B3 G22 Andoain

B4 G23 Azpeitia Gipuzkoa B5 G24 Beasain Bizkaia B6 Durango G25 Eguia system system B7 G26 Eibar B8 Ercilla G27 Irun B9 Etxaniz G28 Ondarreta B10 G29 Renteria B11 Gernika G30 Tolosa B12 G31 Zarautz B13 Otxarkoaga G32 Zumarraga B14 B15 B16 B17 B18 B19 Rekalde MENTAL HEALTH ATLAS

2004 GUIPUZKOA (ESMS) 2013 GUIPUZKOA & BIZKAIA 2017 GUIPUZKOA, BIZKAIA, ARABA

2013 MH NETWORK () INFORMED THE HEALTH PLANNING AGENCY OF GAPS and PROVISION DRIVEN NEEDS : Placement capacity: - Increase of places in day care, community residential care, employment for SMI - Decrease of long-stay beds

RELATIVE TECHNICAL EFFICIENCY (Input-oriented)

BIZKAIA GIPUZKOA

Eficiencia técnica relativa nivel 1 1 Eficiencia técnica relativa nivel 1 1 0,9 0,9 0,8 0,8 0,7 0,7 0,6 0,6 0,5 0,5

0,4 0,4

0,3 0,3

0,2 0,2

0,1 0,1

0 0 Cluster 1 Cluster 2 Cluster 3 Cluster 4 Cluster 5 Cluster 1 Cluster 2 Cluster 3 Cluster 4 Cluster 5

Eficiencia técnica relativa nivel 2 Eficiencia técnica relativa nivel 2 1 1

0,9 0,9 0,8 0,8 0,7 0,7 0,6 0,6 0,5 0,5 0,4 0,4 0,3 0,3 0,2 0,2 0,1 0,1 0 0 Cluster 1 Cluster 2 Cluster 3 Cluster 4 Cluster 5 Cluster 1 Cluster 2 Cluster 3 Cluster 4 Cluster 5 The aim 4

What is the aim of the project? We want to design and develop a Decision Support System (DSS) for helping decision makers (in Mental Health Care) to understand the system where they operate The management of information under uncertainty is based on probability and possibility theories (Klir 2006)

A priori uncertainty Intervention A posteriori uncertainty The only way to U1 U2 reduce UNCERTAINTY is to increase Information: U2-U1 KNOWLEDGE The Generalized Information Theory is based on the concept of uncertainty and INFORMATION. Information is defined in terms of uncertainty decrease. MODELLING MICRO-MANAGEMENT INTERVENTIONS IN BIZKAIA

What could happen if we move a psychologist from an acute service in a MHC to another acute service in other MHC? … with a small increase of beds in acute services in other MHC.

MHC 8 MHC 6 MHC 3 The DSS shows us that the psychologist MHC 4 MHC rate should be reduced in MHC 6 and 19 we need an additional bed in MHC 4

We have changed the current situation into a simulated one, but … This intervention involves 6 variables (we have 57) Is this correct/adequate/appropriate? Is this feasible? MODELLING MICRO-MANAGEMENT INTERVENTIONS IN BIZKAIA: CHENGES IN THE WORKFORCE IN SMALL CATCHMENT AREAS Intervention 1: Move a psychologist in Ambulatory care in Uribe to Day Hospital in Durango

Intervention 2. : Move a psychiatrist in Ambulatory care from Uribe to Sestao. Intervention 3: Move a psychiatrist in Ambulatory care from Ercilla to Barakaldo. MICROMANAGEMENT: SHIFT OF PLACEMENT CAPACITY (BEDS) ACROSS CATCHMENT AREAS

60.0 40

36.11 35 31.79 50.0 30

25 40.0

20

30.0 15

10 6.76 20.0 (%) porcentuales Variaciones Valores de de analizadas las variables Valores 5

1.27 1.30 0.57 0.85 0 10.0 -0.14 -0.21 -0.18 -1.54 -5

-6.21 0.0 -10 Micromanagement Intervention (shift staff and beds across catchment areas in Basque Country)

Effects on system’s efficiency and stability of care in the small MH areas

Small health areas Input management Output management Small health areas Input management Output management (mental health centres) (Input oriented DEA) (Output oriented DEA) (mental health centres) (Input oriented DEA) (Output oriented DEA) Ajuriaguerra = =↓ Ajuriaguerra ↑ ↓ Barakaldo =↑ = Barakaldo =↑ =↑ Basauri =↑ = Basauri =↑ = Bermeo =↑ =↑ Bermeo =↑ = Derio = =↑ Derio = = Durango =↑ = Durango =↑ = Erandio = = Erandio =↑ =↓ Ercilla ↓ =↓ Ercilla =↓ =↑ Etxaniz =↑ =↑ Etxaniz ↑ = Galdakao = = Galdakao ↑ = Gernika = =↓ Gernika =↑ = Ortuella =↑ = Ortuella ↑ = Otxarkoaga =↑ =↑ Otxarkoaga =↑ ↓ Portugalete = = Portugalete = = Santurtzi = = Santurtzi = = Sestao = ↓ Sestao =↑ = Uribe ↑ ↑ Uribe ↑ = Zalla =↑ = Zalla ↑ = Recalde =↑ =↓ Recalde ↑ = Mostly positive/neutral … … positive/neutral. SOMNet Input (W1) for Ideal Output (U3)

INPUT (WOF SOM) OUTPUT (USE SOM) Individual W1 U3 = 10 is given

Psychiatrists value W1 Re-admission Original MIN 0.16 Original MAX 5.23 Estimated MIN 1.37 Estimated Max 2.49 Estimated AVE 1.94

* Low-Medium value (W1 = 1.94) is most likely related to the ideal value of U3 = 10.

Self-Organising Map Network (SOMNet) for Evidence-informed Decision Making in MH care Chung et al, submitted Where next?

Ehealth and Health ecosystems (general) Accountability and transparency Automated coding systems and registries Improved semantic interoperability Linking digital to tangible care – eH - IoT Linking provision, use and financing Kitchin et al. Knowing & Governing Cities Navigation Charts through Urban Indicators . Regional studies, regional science, 2: 6-28, 2015 Real-time dashboards Smart DSS

System thinking in MH Planning

SPATIAL Knowledge & Guided Policy EFFICIENCY ANALYSIS

Financing Modeling-Visualisation

Big data Intelligent indicators Pathways -Interventions

Local Atlas of care Social Network Analysis Logic model/Cptual map SYSTEMS THINKING vs LINEAR HEALTH CARE PLANNING: MIND THE GAP!

BASQUE COUNTRY (SPAIN) / SCOTLAND NHS (UK) ALBERTA /ENGLAND (CQC) Urban MH citiesRISE I-CIRCLE

Visual tools should provide meaningful information that improves organisational learning and decreases ambiguity to support decision making 54 Thanks [email protected]

MH Ecosystem in Catalonia & Basque Country

• Service provision & use in local areas: • ATLAS OF MH CARE (2002-2017) • Financing of health care • Cost of Illness studies (Schiz., Depression, Anxiety, BPD) • Technical efficiency of small catchment areas • Hot-spot and cold-spot analysis • Micro and Meso Interventions in Health care management