Contextualizing the Effectiveness of a Collaborative Care Model for Primary Care Patients with Diabetes and Depression (Teamcare): A Qualitative Assessment Using RE-AIM.

Abstract

We evaluated the implementation of an efficacious collaborative care model for patients with diabetes and depression in a controlled trial in 4 community-based primary care networks (PCNs) in Alberta, Canada. Similar to previous randomized trials, the nurse care manager-led TeamCare intervention demonstrated statistically significant improvements in depressive symptoms compared with usual care. We contextualized TeamCare's effectiveness by describing implementation fidelity at the organizational and patient levels. We used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate TeamCare. Qualitative methods used to collect data regarding the RE-AIM dimensions of Implementation and Effectiveness included interviews with PCN staff and specialists (n=36), research team reflections (n=4) and systematic documentation. We used content analysis, and Nvivo 10 for data management. TeamCare was implemented as intended but with suboptimal fidelity. Deviations from the model included limited degrees of collaborative care practised within the PCNs, including varying physician participation, limited comfort in practising collaborative care and discontinuity of care managers. Despite suboptimal fidelity, respondents identified several implementation facilitators at the organizational level: training, ongoing implementation support, professional and personal qualities of the care manager and pre-existing relationships. Without knowledge of the effectiveness of the intervention in our controlled trial, respondents anticipated improved patient outcomes due to the main intervention components, including active patient follow up, specialist consultation and treat-to-target principles. Despite suboptimal implementation in Alberta's primary care context, TeamCare resulted in improved outcomes similar to those demonstrated in previous randomized trials. A stronger culture of collaborative care would likely have yielded greater implementation fidelity and possibly better outcomes.