Abstract
In order to deliver effective care, it is necessary to organise interdisciplinary activities for older persons who suffer from depressive disorders. This paper evaluated the interdisciplinary team members' perceptions of cooperation in the discharge planning of depressed older persons based on the Chronic Care Model (CCM). A qualitative implementation design was used, data were collected by means of multistage focus groups, and a thematic analysis was performed. Three themes emerged: lack of effective team leadership in the community, the need to change the delivery system, and enhancing self-management support for depressed older persons as well as the participation of their families. It was concluded that nurse managers must find ways of supporting the depressed older persons by better structuring the care, increasing cooperation with organisational leadership, and creating an environment characterised by trust and mutual respect. Distrust can have serious implications for discharge planning collaboration. The development of a common vision of transparency in the organization is important as is a policy of change among leadership and in clinical practice.
Highlights
Depression in older persons is an increasingly complex health problem due to the difficulties involved in distinguishing it from symptoms of physical ill-health, dementia, normal aging, and grief [1, 2]
This paper evaluated the interdisciplinary team members’ perceptions of cooperation in the discharge planning of depressed older persons based on the Chronic Care Model (CCM)
The interventions were expected to help the patients to better cope with everyday life. (iv) Delivery system design requires planning and coordinated actions on the part of multiple caregivers, which could be performed by team members
Summary
Depression in older persons is an increasingly complex health problem due to the difficulties involved in distinguishing it from symptoms of physical ill-health, dementia, normal aging, and grief [1, 2]. Evidence has demonstrated that effective and safe interventions, delivered in collaboration between hospital and community care, are associated with a reduced rate of readmission [3]. Every health care professional possesses evidence-based knowledge, that is, of value to the other members of the team [7]. The above authors suggested that more evidence is needed about which system changes lead to better care as well as quality improvement methods. (v) Decision support means that the team members need to improve their skills by means of more effective training methods. Every depressed older person needs a team led by a nurse or a general practitioner to organize and coordinate her/his care. The team must have expertise, relevant patient information, time, and resources to act rather than just react [10, 11]
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