What work has to be done to implement collaborative care for depression? Process evaluation of a trial utilizing the Normalization Process Model

Linda Gask,Peter Bower,Angela E Simpson,Diane Escott,Simon Gilbody,Janine Archer,Karina Lovell,Annette J Lankshear,David A Richards

doi:10.1186/1748-5908-5-15

Abstract

BackgroundThere is a considerable evidence base for 'collaborative care' as a method to improve quality of care for depression, but an acknowledged gap between efficacy and implementation. This study utilises the Normalisation Process Model (NPM) to inform the process of implementation of collaborative care in both a future full-scale trial, and the wider health economy.MethodsApplication of the NPM to qualitative data collected in both focus groups and one-to-one interviews before and after an exploratory randomised controlled trial of a collaborative model of care for depression.ResultsFindings are presented as they relate to the four factors of the NPM (interactional workability, relational integration, skill-set workability, and contextual integration) and a number of necessary tasks are identified. Using the model, it was possible to observe that predictions about necessary work to implement collaborative care that could be made from analysis of the pre-trial data relating to the four different factors of the NPM were indeed borne out in the post-trial data. However, additional insights were gained from the post-trial interview participants who, unlike those interviewed before the trial, had direct experience of a novel intervention. The professional freedom enjoyed by more senior mental health workers may work both for and against normalisation of collaborative care as those who wish to adopt new ways of working have the freedom to change their practice but are not obliged to do so.ConclusionsThe NPM provides a useful structure for both guiding and analysing the process by which an intervention is optimized for testing in a larger scale trial or for subsequent full-scale implementation.

Highlights

There is a considerable evidence base for ‘collaborative care’ as a method to improve quality of care for depression, but an acknowledged gap between efficacy and implementation
We considered that data collected before the trial would enable us to test out the predictive value of the Normalisation Process Model (NPM) in terms of what happened in the trial platform, and the data collected after the trial would be of particular value in revising the content of the intervention in terms of both the forthcoming large scale trial and wider dissemination
We will present the findings as they relate to the questions derived from the four factors of the NPM

Summary

Introduction

There is a considerable evidence base for ‘collaborative care’ as a method to improve quality of care for depression, but an acknowledged gap between efficacy and implementation. There is a considerable evidence base for collaborative care as a ‘technology’ in the broadest sense for improving quality of care depression in the community [1,2], but an acknowledged gap between demonstrated efficacy of this novel intervention in randomised controlled trials and implementation in everyday practice [3]. Gunn and her colleagues [4] have described collaborative care for depression as a ‘system level’ intervention with four key characteristics: 1. This might include team meetings, case conferences, individual consultation/supervision, shared medical records, patient-specific written or verbal feedback between caregivers

Methods

Results

Conclusion