SINTEF Technology and Society, Department of Health Research, Trondheim, Norway.
Int J Integr Care. 2013 Aug 29;13:e031. eCollection 2013.
Users of mental health services often move between different primary and specialised health and care services, depending on their current condition, and this often leads to fragmentation of care. The aim of this study was to map care pathways in the case of young adult mental health service users and to identify key obstacles to continuity of care.
Quarterly semi-structured interviews were performed with nine young adults with mental health difficulties, following their pathways in and out of different services in the course of a year.
Key obstacles to continuity of care included the mental health system's lack of access to treatment, lack of integration between different specialist services, lack of progress in care and inadequate coordination tools such as 'Individual Plan' and case conferences that did not prevent fragmented care pathways.
Continuity of care should be more explicitly linked to aspirations for development and progress in the users' care pathways, and how service providers can cooperate with users to actually develop and make progress. Coordination tools such as case conferences and 'individual plans' should be upgraded to this end and utilised to the utmost. This may be the most effective way to counteract the system obstacles.
心理健康服务的使用者经常根据其当前状况在不同的初级和专业卫生及护理服务之间转移，这往往导致护理的碎片化。本研究旨在绘制青年心理健康服务使用者的护理途径，并确定连续性护理的主要障碍。
对 9 名有心理健康问题的年轻人进行了季度半结构化访谈，在一年的时间里，他们在不同的服务中进出。
连续性护理的主要障碍包括心理健康系统缺乏治疗途径、不同专业服务之间缺乏整合、护理进展缓慢以及缺乏足够的协调工具，如“个人计划”和病例会议，这些都无法防止护理途径的碎片化。
连续性护理应该更明确地与用户护理途径的发展和进步的愿望联系起来，以及服务提供者如何与用户合作来实际发展和取得进展。为此，应升级病例会议和“个人计划”等协调工具，并充分利用这些工具。这可能是对抗系统障碍的最有效方法。
