Prospective research into the de-institutionalization and regionalization of social relief and protected living responsibilities within municipalities

Since 2015, the provision of extramural ambulatory support (including daytime activities) constitutes a primary responsibility for all municipalities, while sheltered housing and social care specifically, fall under that of larger municipalities. Although experimentation with ambulatory care has been carried out by municipalities for quite some time (e.g., the Housing First program, Maas et al., 2012), it has yet to be embedded structurally. Municipalities have been tasked with allowing no more than 30% of clients to live in facilities and building systems of care that encourage social inclusion and participation as much as possible (UN convention). To this end, the Committee on the Future of Sheltered Housing has argued in favor of altering budget distributions that have originally been allocated on the basis of historical costs. Instead, it has advocated for the adoption of an ‘objective’ distribution model that would work to widen budget allocations, reaching 388 municipalities as opposed to 43. While it remains unclear how ‘objectivity’ within this distribution model is to be measured and carried out in practice, clients are especially concerned with the impacts that this transition has not only on their quality of life but also the extent to which they are consulted and can influence policy throughout its process. 

Currently, municipalities lack clarity over an array of interrelated matters whether that be with regards to numbers and characteristics of target populations, the opening up of the Long-term Care Act (Wlz), macro budgeting, the gradual withdrawal of judicial and mental health care (GGZ) institutions as well as other complex urban issues (APE, 2017). Within this context, Sector parties (Federatie Opvang, GGZ Nederland, RIBW Alliantie, and MIND – National Platform on Psychological Health) have expressed, in a letter issued to the Chamber on 30 August 2017, the need for greater preemptive collaborative focus on setting and addressing pre-conditions within the de-institutionalization and regionalization policy implementation. 

As of October 5th, 2017, pre-conditions for the implementation of ambulatory care include the availability of affordable and varied types of rental housing; debt assistance, income, and participation to support recovery; recovery-oriented treatment accessible within the area; ensuring quality and reactive support; developing a system of (early) identification and nuisance minimization; sustainable cooperation between municipality and insurers and, commitment to self-management, expertise and informal care.

The central aim of the present research is to follow the testimonies and experiences of clients, experts, and other relevant stakeholders as they prepare and engage with decentralization processes and grasp pre-conditions related to deinstitutionalization within specific municipality contexts. The gathering of experience-based perspectives, most importantly those of clients, through the course of this transition could help spur further reflection, research, and lay down paths for action. 

Research questions
Since the aim of this research is to better understand how local governance may facilitate innovation and cultural change as well as achieve inclusive living or ambulatory care in order to improve the clients’ quality of life, we asked ourselves the following questions:

  1. To what extent is ambulantization shaped locally in 388 municipalities (e.g., is a needs assessment conducted among care users; is there collaboration with users)? The database to be built with this information will be a source of learning and knowledge exchange.
  2. How do local governments and stakeholders (social care professionals, policymakers, housing corporations, mental health clinics, police) implement ambulantization?
  3. What are the results at the local level? And how are they valued from different stakeholder perspectives, with clients/care users?
  4. To what extent do these contextual processes and the cooperation (participation and partnership) between local governments and stakeholders explain the outcomes? What works ‘well’ and what ‘best’ practices can be identified?

Stakeholders, including expert clients, will play an active role throughout the research process whether that be with regards to the design of the study (e.g., refining the aim and the question) or the formulation of additional outcome measures. Creating a participatory, learning, and appreciative research environment supports the gradual transition towards de-institutionalization and decentralization of policy and practices by providing interim feedback to relevant actors and allowing them to make appropriate adjustments. By looking at policy and practices in local governance as well as the outcomes that these have on client wellbeing and society generally, the present research builds on contextual and focused analyses to deepen knowledge about governance in specific domains (e.g., healthcare). It also allows for policy visions, processes, and outcomes to be contrasted and compared. The theoretical model below provides an overview of what we know so far about these processes and their outcomes (figure from Boesveldt, 2015). 

Method

  1. From January 1st, 2018, guidelines description of the characteristics of the regional visions (explicitly and including the perspective of end-users), which are then written together with regional municipalities (data collection for management purposes).
  2. Selection on the basis of the main characteristics of a number of these regions and cities for thorough analysis (interviews) based on population, population density (urban/rural) with an eye for specific cases such as the municipality of Ede (a lot of m2) and Apeldoorn (a lot of clinical mental health care). During the review of the regional visions, it may appear that additional characteristics such as control philosophy and degree of participation of users-clients are important as extra eligibility criteria.
  3. From September 2018, discussing and establishing the intended results, monitoring and evaluating the outcomes (and non-expected side effects) from different stakeholder perspectives.
  4. Repeated interim feedback provision using and contrasting case studies from other municipalities, cooperatively determining what works ‘well’ – describing and sharing “best practices”. 

The research project will be carried out over a period of five years and can count on the support of municipalities, service providers, insurers, and clients.

Time investment requested
The time investment requested is as minimal and effective as possible. Interviews are conducted annually lasting on average 1 hour individually, and two meetings are organized with respondents. Moreover, the design of the study is interactive. In addition to the publishing of reports, the University of Amsterdam can organize conversational presentations as a way to introduce and discuss the collected data. These presentations offer researchers a chance to share initial thoughts and findings as well as provide clarification(s). 

Funding
Funding for the research project is determined by municipal and/or regional commitments established on an annual basis.  In this sense, the total amount of funding will depend on participation numbers and required time frames. The budget will then be broken down among the concerned municipality(ies)/region(s). 

Team members and roles
The research team is widely embedded in various networks within municipalities and has extensive expertise and research experience with  regard to local collaboration and client participation. Having worked for municipalities for 15 years, lead researcher Dr. Nienke Boesveldt has a sharp understanding of processes underlying social care, daycare, and assisted living. Responsibility for this research is attributed to the University of Amsterdam and Dr. Boesveldt specifically. Interviews, analyses and research reports are carried out together with eight researchers and a dozen of experts by experience (see ‘about the team for more elaborate information on all of the researchfellows).

For more information, please feel free to contact Dr. Nienke Boesveldt

n.f.boesveldt@uva.nl
+316 42 12 80 51

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