Coordinated individual care planning and shared decision making: staff perspectives within the comorbidity field of practice

ABSTRACT

Integrated treatment is recommended for users with a comorbidity of mental illness and substance misuse. However, due to a divided support system, coordinated individual care planning (CIP) and user participation are emphasised to provide users with the necessary support. One way of increasing user participation is through shared decision making. However, the challenges are evident why coordination and user participation are not used in practice as intended. To contribute with knowledge to bridge the gap between the intended CIP process and practice, this study examined the problems and solutions perceived by staff. Future workshops were conducted with 17 staff members from social services and health care. Problems and solutions were identified within three main areas: organisation and staff knowledge, coordination among staff, and staff attitudes and user participation. The problems are in agreement with previous research, but this study contributes with knowledge regarding solutions. Overall, the solutions expressed relate to improving collaboration between providers and users and having more resources to conduct this work. However, the study also assents to the question if CIP is the best way to coordinate support or if integrated treatment should be the future.

ABSTRAKT

Samordnad behandling rekommenderas för brukare med psykisk sjukdom och missbruk. Men med det fragmentiserade vård- och stödsystem som erbjuds personer med samsjuklighet betonas en samordnad individuell vårdplanering (SIP) där brukaren själv medverkar för att erhålla nödvändigt stöd. Ett sätt att öka brukarmedverkan är genom delat beslutsfattande. Utmaningarna att förverkliga intentionerna om samordning av vård och stöd, samt att realisera brukarmedverkan i praktiken är dock väldokumenterat. För att bidra med kunskap om hur denna klyfta mellan intentioner och praktik kan överbryggas undersökte denna studie de problem och lösningar som personalen uppfattar. Framtidsverkstäder genomfördes med 17 anställda från socialtjänsten och hälso- och sjukvården. Problem och lösningar identifierades inom tre huvudområden: organisation och personalkunskap, samordning mellan personal och personalens attityder, samt brukarmedverkan. Resultaten identifierar problem som överensstämmer med tidigare forskning, men denna studie bidrar också med kunskap om lösningar till dessa problem. Lösningarna handlar om sätt att förbättra samarbetet mellan personal och brukare, samt resurser och förutsättningar för att genomföra detta arbete.

KEYWORDS:

• User participation
• coordinated individual care planning
• substance misuse
• mental illness
• future workshops

NYCKELORD:

• Brukarmedverkan
• samordnad individuell planering
• missbruk
• psykisk ohälsa
• framtidsverkstäder

1. Introduction

This study examines how the gap between intentions and practice regarding making coordinated individual care plans in collaboration with users with a comorbidity and providers from different care units, can be reduced. Comorbidity refers to co-occurring mental illness and substance misuse. Having a long-term comorbidity increases the risk of deteriorating physical and mental health as well as an increased risk of suicide, exposure to violence, a higher risk of crime and socio-economic vulnerability (e.g. deteriorating economic situation and homelessness) (Drake & Brunette, 1998; Nyberg, 2016; Öjehagen, 2011). The vulnerability and complexity of the needs in this group means that care and support from different care providers need to be coordinated and based on the individual's needs.

Integrated treatment whereby users receive treatment for both the mental illness and substance misuse by the same team at the same time has long been recognised as the best treatment for users with a comorbidity (Mueser et al., 2003). Other types of approaches are parallel, meaning that support is given for both illnesses at the same time but from different professionals/teams, and sequential where one condition needs to be treated before the other can be (Mueser et al., 2003). There is a large body of research supporting integrated treatment over parallel and sequential support (Baker et al., 2010; Barrowclough et al., 2001; Cleary et al., 2009; Mangrum et al., 2006; Morley et al., 2016). However, in Sweden and in other countries, coordination of care is emphasised instead due to a parallel support system in which substance use is treated primarily within the social services and mental illness within health care (Matscheck & Piuva, 2020).

Coordinated care implies facilitation from the management, whilst collaboration takes place mostly by informal agreements and adjustments between staff ‘on the same level’ (Axelsson & Axelsson, 2006). The need to coordinate services and collaborate is highlighted so that the users’ participation and influence are included. Despite this emphasis, coordination of care and support has many challenges on different levels (Axelsson & Bihari Axelsson, 2013; Bjerkan et al., 2011; Fox & Reeves, 2015; Jones et al., 2021; Matscheck & Piuva, 2021). Challenges described on an organisational level include separate budgets, different decision-making systems, lack of information-sharing systems, problems with recruiting and retaining staff, and a lack of education regarding collaboration (Edmonstone, 2020). An insufficient dialogue between the different actors may lead to ambiguity regarding the roles and responsibilities (Andersson et al., 2011). Challenges on an individual level include a perceived power imbalance between collaborating staff, lack of common views regarding who is responsible for providing the necessary support and a lack of knowledge regarding each other’s roles and responsibilities, leading to, for example, inter-professional mistrust (Baker et al., 2011; Edmonstone, 2020; Matscheck & Piuva, 2021). Overall, the challenges derive from differences between organisations and professions (Axelsson & Bihari Axelsson, 2013) and bridging these differences is needed to coordinate care.

In addition, user participation is viewed as a challenge due to staff attitudes (Laitila et al., 2011; Matscheck & Piuva, 2021; Schön et al., 2018) and users not being trusted as collaboration partners (Jones et al., 2021). Designations of user participation in policy lack consensus on how user participation should be implemented in practice (Leung et al., 2020; Levin, 2012; Nykänen, 2020). In recent years, shared decision making (SDM) has been described as a main approach to ensure user participation, and users’ preferences and values in care planning (Adams & Grieder, 2014) in social services as well as in psychiatric care (Knutsson & Schön, 2020; Nykänen, 2020; Stovell et al., 2016). Regarding users with a comorbidity, a recent systematic review has shown that SDM is feasible, acceptable, and useful, and is associated with increased quality in the decision-making process and in the decisions made (Fisher et al., 2021). The focus of SDM is that staff and users make decisions based on user and staff knowledge, available treatment options and the users’ preferences and values (Adams & Drake, 2006; Adams & Grieder, 2014; Knutsson & Schön, 2020).

Coordinated individual plans (CIPs) are statutory in Sweden when users need long-term support from more than one care provider (SFS, 2001:453; SFS, 2017:30). There are similar systems of coordinating individual care in other countries, such as Norway, England, and Wales (Matscheck & Piuva, 2020). Coordinated care planning implies that when users need support from both social services and health care, a CIP should be established. Treatment goals as well as provider responsibilities are stated in the CIP (SFS, 2001:453; SFS, 2017:30). When establishing a CIP, the use of both user and staff knowledge and expertise to state the goals and interventions is crucial (Adams & Grieder, 2014; Matscheck & Piuva, 2020; Ness et al., 2014; SALAR, 2018).

However, previous research describes challenges in the process of creating a CIP within the comorbidity field of practice; for example, that users already have parallel support from health care and social services and the CIP does not result in any coordination of support (Matscheck et al., 2019). Another challenge is ensuring user participation in the process of creating a CIP; for example, there is evidence showing that CIPs lack user participation and user preference because, for example, users’ needs are seen at times to be secondary to providers’ responsibilities and costs (Matscheck & Piuva, 2020, 2021).

To strengthen user participation in the CIP process, SDM is emphasised as a supportive approach (Knutsson & Schön, 2020). The CIP process is largely similar to the steps involved in SDM. The five stages of the intended process of establishing a CIP (Knutsson & Schön, 2020; SALAR, 2018) are described in Table 1.

Table 1. The five stages of creating a coordinated individual plan (CIP).

Stage	Content
1. Introduction	A CIP needs to be designed: creating a mutual agenda describing roles and exploring which providers and persons important to the user to invite; obtaining consent from the user to share information between providers
2. Choices and options talk	Informed discussion about choices and treatment options between user and provider(s)
3. Invitation to a CIP meeting	The meeting follows the agenda and treatment goals created by the user and provider
4. CIP meeting	Treatment goals as well as provider responsibilities are stated; decision-making skills and authority in user and providers; making informed decisions and creating a CIP
5. Follow-up CIP plan	Joint action plan; provider responsibilities and treatment goals are followed up

In many ways, people with comorbidity are a vulnerable group and often have a long-term need for different interventions (Mueser et al., 2003) at the same time; there are many shortcomings in coordinating and viewing users’ needs as primary in this work (Matscheck & Piuva, 2021). In other words, there is a gap between the intentions of coordinating support and utilising user participation and SDM in practice. To bridge the gap between intentions and practice, the challenges that prevail and possible solutions need to be further explored and understood. To explore and understand this gap, this study examines what staff working with coordinated care planning with people with comorbidity identify as challenges and solutions to promote collaboration and SDM in the CIP process.

2. Method

2.1. Design

Workshops play a significant role in this study. Workshops have at least a three-fold purpose and focus within research: as a means, as a practice and as a research methodology (Ørngreen & Levinsen, 2017). Here, we used a workshop as a means to co-create a process for participation and SDM in coordinated individual care planning for people with comorbidity; workshops were conducted with staff. We also used workshops as a research method to generate and collect data on how staff perceived the CIP process.

Two types of workshops were used: future workshops (Kensing & Halskov, 1992) and present and future stories workshops (Knutsson & Schön, 2020).

In future workshops, the future users of a product or process participate as co-designers in the design process of the product or process. It is a design based on values committing to democratic and collective shaping of a better practice (Bratteteig & Wagner, 2014). Several studies illustrate how involving different stakeholders as co-designers significantly increases the chance that the process represents the values and meaning of the future users’ real-life context (Simonsen & Robertson, 2013). Present and future stories workshops are based on narrative techniques (Rosson & Carroll, 2007), and the workshop participants are confronted with stories illustrating the core problems and solutions identified in the analysis of the data from the future workshops. These two types of workshops have similarities: they are designed for a democratic process, with specific attention to the individual’s voice. In addition, workshop types rely on brainstorming techniques and several activity steps within a limited time. They also differ; the future workshop starts with the participants’ own reality, and the present and future stories workshops start with the researcher’s interpretation of the participants’ problems and solutions. The two workshop types also work together; the present and future workshops check if the researcher’s understanding of what happened in the future workshops was correct.

In the present study, the workshops were conducted in accordance with the five stages in a CIP process. The topics covered in each workshop included identifying obstacles in today's CIP processes and creating solutions to these barriers to improve the process and promote coordination, user participation and SDM. The first workshop was based on the participants’ general understanding and experiences of obstacles and possible solutions. One starting point was that the staff's knowledge of CIP varied, which is why a short information film of 3 min about the purpose of CIP was initially shown to everyone. Immediately after the workshops, authors OK and UKS analysed and synthesised the information. From this analysis, the core problems and solutions were identified and described. Based on the condensed results from workshop one, the participants had to work further with the problems and solutions for an improved CIP that included participation and SDM.

During the workshops, the participants were divided into groups, and an iterative process of individual work and group discussions took place. For each step in the CIP process, the participants were instructed to first write down their own thoughts and then a group discussion was encouraged where the participants within a group presented to each other and worked further on challenges and solutions. This resulted in both individual descriptions, written down on personal cards with an alias used for each participant, as well as joint written documentation on large sheets of paper. This written material constitutes the empirical data for this study. In the future workshop, the participants were given seven cards with questions (Table 2), and space to quickly answer and reflect on the question. The 3-minute information film was about the purpose of CIP and individuals’ rights to have a CIP established, produced by the Swedish Association of Regions and Local Authorities -SALAR.

Table 2. Questions to participants.

Stage	Questions
1. Introduction	1. How does the film about CIPs correspond with your own experience of CIPs? What are the differences?
2. Choices and options talk	2. How do I go about finding out a client’s problems, needs and wishes?
	3. How do I gain knowledge about a client’s alternatives? And how do I communicate with the client about those alternatives?
	4. How do I express my knowledge concerning a client’s problems, needs and wishes?
3. Invitation to meeting	5. What do you find problematic when you are invited to a CIP meeting?
4. Meeting	6. What problems have you experienced during a CIP meeting?
5. Follow-up	7. What do you find problematic with the follow-up of the CIP?

2.2. Participants

Two workshops in two stages were held with staff from mental health services and social services working with clients with a comorbidity. Staff were recruited to the workshops in connection with a half day seminar on SDM and individual coordinated care planning. Inclusion criteria for participation were working in a service targeted to people with comorbidity, regular use of CIPs and personal experience of participating in or responsible for carrying out a CIP process. In total, 17 staff participated in the study. Table 3 presents the number of participants and gender; a few participants did not attend the second workshop.

Table 3. Workshop participants.

	Workshop 1	Workshop 2
Group 1	10 (6 women, 4 men)	8 (5 women, 3 men)
Group 2	7 (6 women, 1 men)	6 (5 women, 1 man)
Total	17 (12 women, 5 men)	14 (10 women, 4 men)

There was a variety of staff from outpatient mental health care and social services, including social workers, nurses, case managers and housing supporters, which implies a variation in the authority among the participants to make formal decisions (e.g. in care planning).

2.3. Analysis

The source documents (individual and workshop discussion notes) were first transcribed, and then uploaded and analysed using content analysis (Hsieh & Shannon, 2005). This process has been described elsewhere (Knutsson & Schön, 2020).

To further understand the results, an inductive content analysis according to Elo and Kyngas (2008) was performed in which the problems and solutions were categorised. The material was uploaded to the Nvivo software programme (QSR, n.d.) and read, reread and coded. First, open coding was assigned to all aspects of the material. During this process, codes were grouped together in sub-categories based on being sufficiently similar. The sub-categories were placed in main categories. This was an iterative process whereby open coding was carried out at the same time as the categories were being developed. When a code did not fit one of the existing categories, this was coded but not grouped with other codes until similar codes emerged at which stage they were placed together. Thereafter, all the codes, sub-categories, and main categories were revised to look for similarities and differences to make sure they were sufficiently different and did not overlap. During this phase, some of the categories were moved to other main categories when they were assessed as being more aligned with the main category. In addition, two of the main categories were placed together due overlapping (organisation and staff knowledge).

Two of the authors conducted the first content analysis (OK and UKS) and the last step of the inductive coding was conducted by the first author (AJ) with ongoing discussions with UKS. For example, when the first set of codes, sub-categories and categories were developed, these were discussed and compared before the final adjustments were made.

The study was approved by the Swedish Ethical Committee (2019-00657).

3. Results

The analysis revealed three main categories with underlying sub-categories. Within these categories, staff identified both challenges and solutions (Table 4).

Table 4. An overview of the categories and sub-categories.

Organisation and staff knowledge	Coordination among staff	Staff attitudes and user participation
Enabling management	Structure and documentation	Consider variations in users’ health and adapt communication
Time	Facilitating a process over time	Sharing decision-making
Necessary knowledge	Collaborating and making agreements	Relationship and trust

The first category, organisation and staff knowledge, relates to the need for organisations enabling the CIP process with sanctioned time and by providing staff with relevant skills and education. The second category, coordination among staff, relates to providers’ activities to coordinate and facilitate the CIP process between providers and in the documentation. The third category, staff attitudes and user participation, relates to staff enabling mutual trust, user participation and SDM through the CIP process.

3.1. Organisation and staff knowledge

Staff expressed that the management needs to sanction the process regarding working with CIP meetings and that they need to create conditions for staff to work with CIP. These conditions relate to both time and education. Statements regarding time relate to the management giving time to work with the CIP process and statements about staff needing to take the time needed for the CIP process. Overall, it was stated that lack of time was a problem in the CIP process, which, for example, hinders a functioning collaboration because staff do not have the time needed to collaborate with each other during the CIP process, when trying to find a time to conduct a meeting, and in a specific CIP meeting. For other service providers, a lack of time can be interpreted as being unwilling to collaborate, even though this might not be the case.

Solutions that the staff suggested were that the notice about a meeting should be sent out at least 2 weeks in advance and that none of the involved parties should have a time limit for the meeting. Even though it was expressed that lack of time was a problem in the CIP process, it was also acknowledged by staff that it is a process that in the long run could be time saving and that this outcome is important to keep in mind.

Staff expressed that they need to have common knowledge throughout the CIP process; this knowledge relates to how to conduct the CIP process from invitation to follow-up meeting and how to utilise SDM in this process but also knowledge regarding each other’s organisations. Moreover, it was emphasised that staff should work according to recommended methods such as motivational interviewing (MI) and other structured instruments that they are provided with; they also need knowledge regarding these. MI is important because the users at times lack motivation to participate in the CIP process.

Because the staff felt insecure and lacking in knowledge on how to utilise the CIP process, including documentation, they expressed that more education is needed regarding how to write invitations, how to lead and document the meeting and how to facilitate the CIP process in practice.

It can be difficult to gather all the resource people. It is most difficult with the health care. Sometimes I experience a reluctance from health care to invite to a CIP meeting, I think it depends on insecurity, lack of knowledge and lack of time, even though we know that in the long run, it would save time to gather all the resources around the user.

Another challenge with the CIP meeting, which can be related to staff insecurity and lack of knowledge and skills about the intended process, was too many providers present in the meeting. This problem can be solved by inviting relevant staff regarding their knowledge and responsibilities. Having knowledge of each other’s organisations ensures that the right person is invited to the meeting. The right person, for example, has a mandate to make decisions and has knowledge of the user. Not knowing who to invite from other providers and inviting the wrong people was expressed as a problem in the CIP process.

Not knowing who has a mandate [to make decisions]. Frequently, the decision mandate is higher up in the organisation and they seldom participate in the CIP meetings.

3.2. Coordination and collaboration among staff

The next category, coordination among staff, relates to provider activities to coordinate and facilitate the CIP process between different providers and in the documentation. These activities naturally relate to organisational enablement of the CIP process as described above.

Staff expressed that the CIP meeting often lacked structure and an agenda; at times, the CIP meetings focused mostly on the service providers lack of resources instead of what they could offer the user.

Users’ preferences are not central; rather the service providers possibilities/conditions to meet these preferences.

The solutions expressed by staff regarding this problem were to make sure the meeting has a clear structure and that everyone knows what is expected from them before the meeting so that they can prepare. In addition, among other reasons, knowledge about the documentation was at times perceived as insufficient. Not knowing what was expected from everyone and inadequate documentation regarding what has been decided upon are barriers to a meaningful follow-up meeting.

Staff emphasised the need to facilitate the whole process over time to deal with these problems in the preparation for the meeting and the follow-up meeting. The process starts with preparatory conversations both between staff and between staff and users, followed by the actual CIP meeting and follow-up meetings over time. To overcome the problem whereby only the actual CIP meeting is in focus, it was emphasised that the whole process needs to be facilitated and solutions for enabling this were expressed.

No, it doesn’t work so well in most cases. One ‘checks off’ that one has conducted a CIP but the users have not been involved in the process before the meeting; instead, they are given a finished suggestion.

Regarding the preparation phase, it was stated that both staff and users need to be prepared for the meeting. Staff expressed that they could help the user prepare by, for example, providing information and options before the meeting. The information provided in the invitation is important to enable preparation. The solutions suggested by staff to solve the problems with the follow-up meeting (substitutes without the right knowledge are sent to the meeting, the meeting is not prioritised, it is hard to find a time when everyone can participate, and staff turn up unprepared without the necessary knowledge) are that the follow-up meeting is arranged at the CIP meeting and that everyone turns up prepared for the meeting. Preparation for the follow-up meeting can, for example, be done by reading the documentation from the last meeting.

Staff expressed that they could prepare for both types of CIP meetings by having discussions with staff from other organisations before the meeting and by gaining knowledge of the users’ situation. Pre-meetings with staff from other organisations are needed because staff from different organisations have different views on users’ problems and who is responsible. Staff implied that gaining knowledge about the user is done by combining the use of standardised instruments on one occasion and getting to know users over time, talking with other service providers and reading the documentation before the meeting. In addition, involving users’ relatives was suggested as something that could be done to a greater extent to get more information regarding the users. In agreement with this, staff also expressed that they could involve the users’ network and relatives during the CIP process to a higher degree.

From the staffs’ perceptions, collaboration was found to be a complex issue with several problems but also solutions. Staff expressed that overall, the collaboration and communication between different service providers could be better. For example, staff do not always show up for the meeting and do not send a substitute; agreements are not made, or staff do not follow through on plans that are made; some of the service providers do not invite to a meeting even though they see a need for it. Besides turning up for the meeting and following through on plans that are made, suggested solutions involved enhanced collaboration. This can be done by having common activities for staff from different organisations; for example, participating in learning activities together, having a shared calendar or specific days on which CIP meetings are held. Integrating the services for users and sitting in the same facilities was suggested as a solution to enhance collaboration. Regarding the physical environment, staff suggested that the location of CIP meeting can be adjusted individually; for example, home visits, at the social services, in a health care setting, or digital meetings.

An additional part of collaboration is that staff help each other out by discussions and sharing knowledge. According to the staff, this can be done both in written form and verbally. Written information regards decisions and the basis for the decisions given from staff in a decision-making position to the staff who work on the housing support. Verbal information involves discussions between staff within the organisation but also with staff in other organisations and mostly aims at gathering information about users and relevant options.

3.3. Staff attitudes and user participation

Staff expressed insights that a lack of user participation and the power imbalance between staff and users were problems in the CIP process. However, the need to work together with the user was emphasised and an outcome of the CIP process is enhanced user participation with clearer decisions, making it easier for the users to be involved in the process.

Often it is not the users’ plan, rather it is a plan for the municipality and health care and user participation is missing.

Whilst recognising that users should influence the CIP-process, it is also acknowledged by staff that the users’ mental health status can influence the process due to having problems understanding the process and a mental illness can decrease the users’ ability to participate. This act of balance between facilitating user participation and considering the users individual abilities indicates the complexity of working with users with a comorbidity. Staff expressed that they adjust the communication to the users’ situation and abilities. This can be done by staff utilising their knowledge by applying methods such as MI and by staff giving both written and verbal information.

I try to get users to be active and take responsibility for their own will and what consequences this can have. I clarify so that the user can understand and participate and focus on their own strengths and weaknesses.

Staff expressed that motivational work with users could be enhanced and used to a greater extent, because users lacked motivation and will at times. It was also expressed that the users’ behaviour can be a problem in the CIP process. For example, users not consenting to the meetings and sharing of information and users having different views of their needs compared with the staff. These are viewpoints that contradict the insights and instead puts more responsibility on the users themselves.

What problems to you experience with the follow-up meeting? Users changing their minds regarding what is decided because they do not believe it was the right choice.

Staff expressed aspects of sharing decision making, regarding what is done now but also what could be done to a greater extent. For example, they emphasised the importance of listening to users, giving information and alternatives, and asking questions, with the aim of working together with users. Overall, it was expressed that giving information and options should be done throughout the CIP process. For example, working together and giving options were demonstrated by staff and users searching for different options together and discussing these. Overall, communication skills are viewed as important to build trust and establish relationships with users, leading to successful CIP meetings.

Asking the right questions (there are models) to confirm that the user has said what he/she wants to say. Establish trust to get honest answers. Talk with relatives about their perspectives. Give this process TIME. It is about trust and relationships.

In the CIP process, staff also share their views with users to have a common ground, which was indicated in the workshops. Staff expressed that they need to ask the user if it is okay to express their views before doing this. These views should be presented as reflections, not truths. This facilitates that further exploration together with the user.

In conversations with the user, mention what I see – but not present this as a truth – rather explore if the user thinks that there is relevance.

Having communication skills is important when expressing views because these, at times, relate to users’ difficulties and problems connected to the users having a comorbidity. However, even though it was explicitly asked in the workshop how staff present their views regarding users’ problems, needs, and wishes, very little information regarding was forthcoming. This lack of information indicates that expressing views is a complex matter and something staff need to reflect on more.

4. Discussion

The aim of this study was to contribute with knowledge regarding the gap between the intended CIP process and practice by examining what staff working with coordinated care planning with people with comorbidity identify as challenges and solutions to promote SDM and coordination of care in CIP processes. The perceived challenges in the CIP process relate to organisational, unit and individual attributes, such as the lack of conditions needed to facilitate the CIP process, and enabling user participation and adequate collaboration between staff in this process. The solutions put forward by the staff relate to a more knowledge-based care with additional resources within the organisations involved and a focus on improved collaboration between providers and users.

Obstacles for coordination of care and user involvement within the assessments presented in this study are in line with previous research (Baker et al., 2011; Edmonstone, 2020; Laitila et al., 2011; Matscheck & Piuva, 2021; Schön et al., 2018), demonstrating a gap between practice and the intended CIP process. Even though the intention is to undertake the CIP process in stages, whereby users and staff can inform themselves about alternatives and preferences to enable informed decisions, the results illustrate a partial process with a sole focus on the CIP meeting. Not utilising the preparation stages caused problems such as a lack of user participation, an unclear agenda for the meeting, and staff lacking the necessary decision-making mandate. This practice of CIP is in agreement with previous research (Matscheck et al., 2019), and becomes extra problematic in a fragmented care context in which people with comorbidity find themselves (Matscheck & Piuva, 2020).

However, this study not only confirms the challenges that still exist in the work of coordinating care and involving users in these activities. It also provides co-created solutions to these barriers from staff with experience of CIP processes. This experiential knowledge can be seen as an important contribution to the development of user participation in coordinated care planning with people with comorbidity. A clear desire for improved coordination of efforts between care providers is expressed. Nevertheless, this is described as a complex issue and clear leadership is required that can sanction such work. For example, prioritising collaboration between care providers, instead of monitoring and limiting their respective core tasks or budget, is suggested as a solution to enhance coordination and collaboration. These solutions could bridge the gaps between organisations that are evident when it comes to challenges in coordination of care in the comorbidity field (Axelsson & Bihari Axelsson, 2013). In addition, these solutions agree with working towards integrated treatment instead of a parallel approach. Integrated treatment is an evidence-based approach to treating users with a comorbidity and recommended in previous research (Baker et al., 2010; Barrowclough et al., 2001; Cleary et al., 2009; Mangrum et al., 2006; Morley et al., 2016). Working towards a more integrated service provision is also expressed in previous research on CIPs within the comorbidity field (Matscheck et al., 2019; Matscheck & Piuva, 2020) when suggesting that multidisciplinary teams could be more optimal than CIP when coordinating support. This would potentially ensure users’ rights in the coordination by, for example, enhancing continuity among staff and encountering staff with a formal decision-making mandate (Knutsson & Schön, 2020; Matscheck & Piuva, 2020).

Regarding user participation, staff expressed that they could involve users and their relatives to a greater extent. Users not being involved in the CIP process is in agreement with previous research (Matscheck & Piuva, 2020, 2021). One solution to this is to utilise SDM to a greater extent, which is consistent with previous research that has stated that SDM is perceived to be acceptable, feasible and appropriate when managing comorbidity (Fisher et al., 2021). However, the results in the present study also highlight that staff see users as co-responsible; not wanting to participate or be involved; not coming to meetings; or not consenting to arranging meetings. In addition, users’ health could influence their ability to participate. That users’ motivation and health status can impinge on their ability to participate is in agreement with users’ perspectives of participation (Jones et al., 2021).

Previous research and guidelines regarding CIP state that user preferences should be the starting point when working with CIP (Adams & Grieder, 2014; Matscheck & Piuva, 2020; Ness et al., 2014; SALAR, 2018) and in policy texts also that CIP is ‘the user’s plan’ (SALAR, 2018). However, this is a balancing act because there is a risk of facilitating a process that focuses too much on the users, neglecting staff responsibilities. A CIP plan contains user's goals, yet also clarifies the support that staff are to offer, for the individual to achieve these goals.

In the present study, staff provide suggestions regarding how they can involve the users to a greater extent, while still seeing their role as facilitating working together with users, listening to their views, sharing information, preparing the user for the meetings, for example, by using conversational methods such as MI. That is, involving users in the whole process with both information and option talk. These are also viewed as solutions to bridge the gap between intentions regarding user participation and SDM and actual utilisation in practice.

A limitation with this study may be the one-sided perspective on the staff perspective. The CIP process is a collaboration with the client and sometimes also relatives. Their descriptions of obstacles and solutions for a CIP process characterised by cooperation and shared decision-making are, of course, indispensable knowledge. This knowledge has also been studied within the project in which we operate and has been published (Knutsson & Schön, 2020). However, in this study, the purpose is to explore staff's experiences of obstacles and solutions for a well-functioning CIP work, which in itself can contribute with valuable knowledge both to an unexplored field of knowledge and to practice. Another possible limitation is that the author who conducted the last inductive content analysis (AJ) was not present when the data were collected. Being present at data collection could enhance the understanding of the material, which could influence the analysis. However, throughout the process, discussions between authors AJ and UKS took place to check for coherence in the analysis and the workshops.

5. Conclusions and implications for practice and research

The present study illustrates that the problems that staff perceive in the CIP process can be solved by facilitating staff and users working together to reach the joint treatment goals. A first step is to utilise the complete CIP process in practice, not just one CIP meeting. To facilitate this process, the organisations within which the individual care planning takes place need to enable this way of working by making time for education, common activities, and individual care planning. In addition, this study agrees with the question raised by Matscheck et al. (2019) whether integrated treatment is preferred instead of coordinated individual support to ensure continuity, user participation, and utilisation of the necessary care in practice.

The main value of this study is the suggested solutions to commonly expressed problems in the CIP process. Because staff from different organisations participated and the results agree with previous research, there is reason to believe that staff and managers at other sites can utilise the solutions within their own organisation and collaboration processes. However, additional knowledge is needed regarding how these solutions are implemented in practice in a way that both users and staff perceive as a functional way of working. The approach, to involve staff as co-designers in future workshops did not only identify barriers and create solutions for user participation in CIP relevant to staff’s real-life context (Simonsen & Robertson, 2013). In addition, the future workshops provided an opportunity for staff to reflect on their practice and triggered an implementation of user involvement.

Acknowledgements

We are deeply grateful to all the staff for their time and commitment during the workshops and for sharing their indispensable knowledge and experiences.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Swedish Council for Research on Health, Welfare and Working life (FORTE) [grant number 2018-0134].

Notes on contributors

Amanda Jones

Amanda Jones is a social worker and PhD-student in health and welfare. Her research interest regards users with a comorbidity of substance use and mental illness/neuropsychiatric disorders, and participation in social work encounters.

Ola Knutsson

Ola Knutsson has a Ph.D. in Human–Computer Interaction and is Associate Professor at Stockholm University. His research focuses on participatory design of learning and work environments, the use of design patterns, and research on digital literacy.

Ulla-Karin Schön

Ulla-Karin Schön is a social worker and Professor in social work. Her research interest lie in the field of disability, especially disabled people’s opportunities to participate in social life, in meetings with social services and health care, and in education.