Abstract
BackgroundMental-physical multi-morbidities pose challenges for primary care services that traditionally focus on single diseases. Collaborative care models encourage inter-professional working to deliver better care for patients with multiple chronic conditions, such as depression and long-term physical health problems. Successive trials from the United States have shown that collaborative care effectively improves depression outcomes, even in people with long-term conditions (LTCs), but little is known about how to implement collaborative care in the United Kingdom. The aim of the study was to explore the extent to which collaborative care was implemented in a naturalistic National Health Service setting.MethodsA naturalistic pilot study of collaborative care was undertaken in North West England. Primary care mental health professionals from IAPT (Increasing Access to Psychological Therapies) services and general practice nurses were trained to collaboratively identify and manage patients with co-morbid depression and long-term conditions. Qualitative interviews were performed with health professionals at the beginning and end of the pilot phase. Normalization Process Theory guided analysis.ResultsHealth professionals adopted limited elements of the collaborative care model in practice. Although benefits of co-location in primary care practices were reported, including reduced stigma of accessing mental health treatment and greater ease of disposal for identified patients, existing norms around the division of mental and physical health work in primary care were maintained, limiting integration of the mental health practitioners into the practice setting. Neither the mental health practitioners nor the practice nurses perceived benefits to joint management of patients.ConclusionsEstablished divisions between mental and physical health may pose particular challenges for multi-morbidity service delivery models such as collaborative care. Future work should explore patient perspectives about whether greater inter-professional working enhances experiences of care. The study demonstrates that research into implementation of novel treatments must consider how the introduction of innovation can be balanced with the need for integration into existing practice.
Highlights
Mental-physical multi-morbidities pose challenges for primary care services that traditionally focus on single diseases
As the pilot study was run under naturalistic conditions, this presented a unique opportunity to explore the extent to which collaborative care was implemented in routine primary care, potentially leading to better understanding about barriers and challenges associated with translation of complex interventions outside of trial settings
Primary thematic analysis at T1: experience of collaborative care Preliminary themes from the thematic analysis represent two broad constructs: ‘Coming together’ and ‘Staying apart’ (Table 1). These themes relate to perceptions about how the collaborative care model encouraged novel ways of working that were distinguishable from working practices typically seen in primary care where Psychological wellbeing practitioner (PWP) and Practice nurse (PN) work separately, both geographically and in terms of therapeutic focus
Summary
Mental-physical multi-morbidities pose challenges for primary care services that traditionally focus on single diseases. In recent years, United Kingdom (UK) health policy for managing LTCs has been informed by United States (US) approaches to quality improvement and service redesign: the chronic care model and the ‘risk pyramid’ developed by Kaiser Permanente [6]. These US models are underpinned by a philosophy that appeals to whole system perspectives in which healthcare systems are seen as the main barrier to delivering effective treatments for LTCs. The chronic care model emphasises that care improvement is linked to the redesign of inter-dependent components in health systems: delivery system design; patient-provider relationships; decision support tools; clinical information systems; community resources; and organizational factors, such as leadership
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