Implementing a stepped-care approach in primary care: results of a qualitative study

Abstract

BackgroundSince 2004, 'stepped-care models' have been adopted in several international evidence-based clinical guidelines to guide clinicians in the organisation of depression care. To enhance the adoption of this new treatment approach, a Quality Improvement Collaborative (QIC) was initiated in the Netherlands.MethodsAlongside the QIC, an intervention study using a controlled before-and-after design was performed. Part of the study was a process evaluation, utilizing semi-structured group interviews, to provide insight into the perceptions of the participating clinicians on the implementation of stepped care for depression into their daily routines. Participants were primary care clinicians, specialist clinicians, and other healthcare staff from eight regions in the Netherlands. Analysis was supported by the Normalisation Process Theory (NPT).ResultsThe introduction of a stepped-care model for depression to primary care teams within the context of a depression QIC was generally well received by participating clinicians. All three elements of the proposed stepped-care model (patient differentiation, stepped-care treatment, and outcome monitoring), were translated and introduced locally. Clinicians reported changes in terms of learning how to differentiate between patient groups and different levels of care, changing antidepressant prescribing routines as a consequence of having a broader treatment package to offer to their patients, and better working relationships with patients and colleagues. A complex range of factors influenced the implementation process. Facilitating factors were the stepped-care model itself, the structured team meetings (part of the QIC method), and the positive reaction from patients to stepped care. The differing views of depression and depression care within multidisciplinary health teams, lack of resources, and poor information systems hindered the rapid introduction of the stepped-care model. The NPT constructs 'coherence' and 'cognitive participation' appeared to be crucial drivers in the initial stage of the process.ConclusionsStepped care for depression is received positively in primary care. While it is difficult for the implementation of a full stepped-care approach to occur within a short time frame, clinicians can make progress towards achieving a stepped-care approach, particularly within the context of a QIC. Creating a shared understanding within multidisciplinary teams of what constitutes depression, reaching a consensus about the content of depression care, and the division of tasks are important when addressing the implementation process.

Implementation of a collaborative care model for the treatment of depression and anxiety in a community health center: results from a qualitative case study

“…Despite their efforts, many felt that communication and relationships between staff could be improved. Suggested improvements included direct communication between primary care providers and the consulting psychiatrist, and confirmed previous research showing that structured, multidisciplinary team meetings were extremely helpful in creating treatment plans and facilitating program implementation 15,28. As emphasized by Oishi et al, weekly team meetings can serve as a powerful tool in promoting relationships among team members.…”

Primary Care Professional’s Perspectives on Treatment Decision Making for Depression with African Americans and Latinos in Primary Care Practice

“…Primary care providers perspectives on depression treatment in the context of primary care have been extensively studied 24–27 . These studies have focused primary care professionals’ perspectives on the recognition of depression 24 , screening tools for depression 25 , referral to specialty care 26 and implementation of a collaborative care model for depression treatment 27 . Hardly any attention has been paid to professionals perspectives on the depression treatment decision making process with ethnic minority immigrant patients 28 .…”

Population Health Management Telehealth Intervention Medical Research Treating Comorbid Clinical Obesity and Depression in Geriatric Patients Part One: Review of Tele-Medicine Scientific Research

“…Synthesis of the research across studies supports the consistent and positive effects of PA on mental health in obese senior adults with depression [36][37][38][39][40]. The reduction in depressive symptoms in clinically obese adults with depression is important in the interest of managing obesity and ultimately eliminating obesity-related morbidity and mortality Xin et al [21].…”