Integrating child welfare and mental health services: 'The Acute Project' - a Norwegian pilot study

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Introduction: A high number of children and adolescents receiving child welfare services are in need of mental health services. In Norway, child welfare services and mental health services are organized separately, and no formal mechanisms have existed to ensure collaboration and coordination of services across the organisations. Child welfare is organised under social services in the municipality, while mental health services are organised under the state financed specialist healthcare. For children and their families, in need of both services, this has led to fragmented and poorly coordinated services, and collaboration between providers have been based on ad hoc arrangements. Practice changed implemented: To create a more coherent service the municipality of Kristiansand developed a project – Inter-organisational acute services for children and adolescents (short: the Acute Project) – targeted towards children experiencing acute situations (e.g. suicidal attempts, domestic violence) where they potentially are in need of services from both child welfare and mental health services. Sub objectives in the project are to (a) develop common routines for providers in acute situations, (b) increase providers' competence (c) implement measures to strengthen parents' abilities to handle the acute situation in their own home (e.g. avoid institutionalisation), and (d) ensure coordinated follow-up after the acute situation has stabilised. Key stakeholders in the project are the child welfare guard and the acute-ambulatory unit in the hospital. The regular child welfare service, who takes over the responsibility for a case after the acute situation, is also partly involved. Various measures have been introduced to reach the objectives. The most significant is the abolishment of the professional secrecy across the organisations, meaning that child welfare and mental health services currently are allowed to openly exchange information, which was not the case previously. The Acute Project has received financial support from the Norwegian government, and it is the first (large-scale) attempt in Norway to improve integration across these services. The project period is 2013-2016. Key findings: As researchers we have followed the project since 2014, conducting interviews with a range of providers and children/families who have received combined services. We have also taken part in workshops and surveyed the number, content and outcome of acute case. The research will continue to the ending of the project period. Here we present findings with an emphasis on providers' experiences and perspectives. Employees in both child welfare and mental healthcare report of increased knowledge of each other, increased trust and an understanding of being more equal. The changes are related to their attendance in regularly held common seminars, including case discussions and lectures. Routines to support the integration of services have been introduced, and imply that the parts must telephone each other for each acute case. Furthermore, staff from the acute-ambulatory unit sits in with the child welfare guard once a week, thus bringing the collaborating partners closer to each other. The significance of abolishing the professional secrecy are debated among staff, but in sum it is safe to say that it provides a legal structure that makes communication across the sectors easier. At this point in the project period we will argue that the parties have increased their competence, in particular their 'collaboration competence', and the routines that have been introduced function quite well, but they are also subject to constant revision. Whether the objective of providing alternative measures and strengthening parents' capabilities to deal with the acute situation in their own home is reached within the project can be difficult to determine for a single provider, but there seems to be an agreement that the project helps preventing institutionalization. The follow up after the acute situation seems to have been less affected by the Acute Project. Improved integration and coordination of services is predominantly taking place within the acute situation, less after. Routines are currently being developed to ensure a smoother transition between the acute units and the regular child welfare service. Lessons learned: A number of factors (e.g. legal, fiscal and professional) hamper integration and coordination across child welfare and specialist mental health services. The Acute project removes some of these barriers. However, there is concern about how the collaboration will be affected when/if the abolishment of the professional secrecy ceases. Conclusion: The Acute project tests a form of service integration rarely seen in Norway, by trying to integrate services from the social- and the healthcare sector. If we are to address the complex needs of children and adolescents in need of help from both sectors, measures like the Acute project is highly recommendable.