Background
Mental disorders are high in prevalence [
1], pose a significant burden for those affected [
2] and entail high costs both in health care and economically [
3,
4]. Comorbidity rates between mental disorders are substantial, with an estimated 44% of patients having two and 22% having three or more mental conditions [
5]. Most patients with mental disorders are first and partly exclusively cared for in primary care settings [
6]. Guidelines in the UK, the Netherlands and Germany recommend collaborative and stepped care as models of health care provision for mental disorders [
7‐
9]. While collaborative care models differ in their particular designs, the essential elements are: 1) team-driven care, i.e. care is provided in a coordinated way by a multidisciplinary group of health care providers, 2) population-focused, i.e. care aiming at a defined group of patients, in this case those with mental disorders, 3) measurement-guided, i.e. care being guided by systematic patient-oriented outcomes and 4) evidence-based care [
10]. Stepped care further adds evidence-based care pathways with accurate alignment of care intensity based on illness severity, thus offering the lowest step of care intensity required. Moreover, the adaptation of care intensity is assured by systematic monitoring and subsequent stepping up or down or maintaining of care intensity [
11].
Collaborative care models have been proven effective for a range of mental disorders [
12‐
14].
To assess the effectiveness of a collaborative and stepped care (CSC) model for patients with the most common mental disorders (depression, anxiety, somatoform and alcohol-related disorders [
15]), we conducted a prospective cluster-randomized controlled trial (RCT) in primary care. Details on the
Collaborative and Stepped Care in Mental Health by Overcoming Treatment Sector Barriers (COMET, NCT03226743) can be found in the study protocol [
16]. A collaborative care network of primary care physicians (PCPs) and mental health professionals (= MHPs: registered outpatient psychotherapists and psychiatrists, inpatient and day-clinic mental health providers) was built in the metropolitan area of Hamburg, Germany. To facilitate collaborative care, we established an online scheduling platform, where PCPs could directly schedule psychotherapist or psychiatrist appointments with MHPs from the network for their patients, thus lowering the threshold for psychotherapeutic and psychiatric care. Furthermore, we encouraged and financially reimbursed exchange between PCPs and MHPs, both regarding shared patients (e.g. via phone calls or specific treatment reports) and by offering quarterly CME-accredited network meetings that combined professional training and interprofessional dialogue. Furthermore, recommendations of stepped care pathways were given based on the clinical diagnosis of the PCPs and following an evidence-based algorithm. The COMET CSC model distinguishes itself from previous CSC models by implementing the aforementioned innovations in the existing structures of usual care with its small-practice structure in Germany, without adding new care professional roles or external facilitators, e.g. study nurses or care managers. Moreover, it explicitly accounts for the high rate of comorbidity between mental disorders by addressing the four most common mental disorders, which frequently co-occur and pose challenges to differential diagnostics especially in primary care.
The effectiveness and implementability of complex care models like the CSC model in COMET depend on the ability and willingness of the involved care providers to adopt new tasks and to collaborate. Thus, it is indispensable to consider their perspectives. Previous studies on CSC models in primary care have revealed different challenges for collaboration. Facilitators for collaboration were identified in clear care provider roles, sufficient coordination and personal contacts [
17‐
20]. In contrast, care providers in CSC studies criticized when collaboration came along with too many and/or not sufficiently remunerated tasks, against the background of already high workload and little treatment capacities [
19‐
21]. Difficulties arose when interests of care providers diverged too largely [
17,
19] and when communication, interaction and/or feedback pathways were deficient, both structurally and on content-level [
20‐
22].
Considering these prior study results, we conducted a process evaluation alongside the COMET-trial. This evaluation focused on collaboration experiences between PCPs and MHPs, both within and outside the COMET network. In addition to the existing research, we explicitly accounted for the usual mental health care situation at baseline by inquiring on the collaboration experiences of the care providers in usual care before trial implementation. Also, we included a broader range of common and often comorbid mental disorders than in most disorder-specific trials, in order to mirror prevalence within the general population and to build a closer link between trial conditions and usual mental health care. Moreover, as PCPs and MHPs in Germany predominantly work in small practices, we wanted to shed light on the collaboration challenges in outpatient care without co-location, which may differ from CSC models implemented in hospitals or health organizations [
23]. Furthermore, we focused on potential difficulties in interprofessional relations, as these have been considered a barrier to collaboration beforehand. The research question was: How do PCPs and MHPs experience and evaluate collaborative care within the COMET study against the background of usual mental health care?
Discussion
The present process evaluation of the COMET study shed light on the PCPs’ and MHPs’ perspectives with regard to collaborative care within a newly implemented CSC model, against the background of usual mental health care and collaboration. The usual mental health care situation was described by both the CSC and the TAU group as impaired by insufficient resources, with collaboration mainly taking place, if at all, within informal local networks. Taking this into consideration, the care provided within COMET was appraised as improved due to shorter waiting times, more personal contacts, increased mutual knowledge and slightly improved feedback loops. Yet, collaboration expectations were only partly fulfilled and optimal collaboration, in the interviewees’ eyes, would have consisted of more frequent and more in-depth information exchange, in a denser and more consistent network in close proximity and with more structural changes to allow for collaboration time and remuneration.
The importance of personal contacts, e.g. as enabled by the CSC network meetings, has been identified as a key factor for fostering collaboration, with closer contact in terms of regular team meetings or co-location as even more helpful [
17‐
20]. This reflects the COMET participants’ wish for a more local network instead of the regionally wide-spread COMET network and underlines the specific challenges of collaborating in independent outpatient practices. This way of rather “horizontal integration” substantially builds on the participants’ willingness to collaborate and stands in contrast to the more “vertical integration” in hospitals or overarching health organizations, where e.g. leadership can enhance collaboration [
23,
36]. Despite the variety of pathways that led to the creation of informal networks, personal contacts were central to most ways of connection. A key question, subject to differences in health care systems, is to what degree these personal contacts have to be formalized, how close collaborative care needs to be and how evidence-based collaborative care models can be implemented and aligned with health care specifics [
37]. In line with previous research [
19,
20], COMET PCPs and MHPs welcomed the benefits of participating in a network of committed care providers, sharing the goal of better caring for patients. Especially in the COMET PCPs’ eyes the study succeeded in allowing for shorter referral pathways, congruent to previous studies on collaborative and stepped care that solely focused on depression and on somatoform disorders [
21,
31]. While in COMET communication and feedback loops only slightly improved despite the participants’ wish, this represented an important component of collaboration in a systematic qualitative review by Overbeck et al. [
20] and should be addressed in future CSC models. Helpful strategies, according to the participants, could include systematic feedback rules, e.g. by setting fix time points in the treatment process for mutual reports, remuneration for exchange activities or the development of acceptable digital communication channels, such as secure email systems or shared electronic records. This has to be considered against the backdrop of the overall mental health care problems with lack of resources, deficits in remuneration of collaboration and high workload. These facts prominently emerged in the COMET study as inhibiting factors of the participants’ commitment and collaboration, concordant with previous trials [
19‐
21].
In addition to these structural barriers that impeded on the implementation of COMET, interprofessional differences rose up repeatedly and as a major barrier to collaborate in such a “horizontal” [
36] collaboration setting. While role definitions were partly clear as to which tasks were primarily realized by either PCPs or MHPs, several conflicts arose: e.g. the doubts of MHPs with regard to PCPs’ mental health competencies, the responsibility for caring for mild to moderate mental disorders, the felt lack of esteem on the MHPs’ side and the impression on the PCPs’ side that MHPs partly were reluctant to cooperate. These cultural differences and divergences in interests between the professional groups, also described as “territoriality” [
36], were equally cited as counterproductive in studies realized in other countries [
20,
38]. In previous research and in COMET [
20,
39], both PCPs and MHPs worried about their autonomy and status. At the same time, in COMET and in other studies, MHPs have been identified as the professional group more likely to be subdued when care is advancing towards integrated care, as this is mostly realized within the medical system [
40]. To counteract the tendency towards “territoriality”, both provider groups have to be involved on equal level, paving the way towards a more “altruistic” stance to collaboration [
36]. Examples of how this might be realized in mental health care are accounting for the competencies of all care provider groups in designing stepped care pathways and in deciding on whether to step up or down treatment or adequately paying the services provided by all professional groups, especially regarding consultation time and collaborative activities. To diminish interprofessional difficulties, and in addition to the identified personal encounters as helpful, further strategies can be applied to increase mutual understanding, develop a shared language and treatment approach. These include e.g. interdisciplinary further training as already researched on in physicians and nurses [
41], well-embedded digital exchange channels [
42] and interprofessional case conferences [
43]. Existing international guidance on how to foster collaborative practice and interprofessional education [
44,
45] should be consulted and adapted to the specific setting, such as care networks without co-location.
Taken together, the present process evaluation of the COMET trial reveals the importance of taking into consideration the different care provider roles, of creating room for interprofessional encounter in local networks and of improving general mental health care conditions in order to foster collaborative care in usual care settings for the most common and comorbid mental disorders. Collaborative care, if realized, requires effort but can improve mental health care substantially.
Strengths and limitations
The results of the present process evaluation add to the current knowledge by examining the implementation of a CSC model closely aligned to usual mental health care without additional health care professionals, such as care managers or study nurses. Moreover, collaboration experiences within the CSC model were explicitly embedded in the usual mental health care experiences of the involved care providers, thereby anchoring the results in the overall health care situation. Study results have to be considered in light of the following strengths and limitations. Adopting a qualitative approach allowed for capturing in depth the experiences of the participants, especially as we conducted interviews at two time points and could thus retrace the changes in collaboration. Collaboration was investigated from both sides of the collaborating professions, i.e. PCPs and MHPs, and the sampling procedure aimed at further increasing heterogeneity within the sample. Since both the COMET trial participation and the interview participation relied on the participants’ willingness to engage in research, a self-selection bias towards health care providers who were interested in collaboration can be assumed. Answers might have been influenced by social desirability and by a self-bias with regard to the evaluation of the care providers’ own work. As to the process of interviewing and analyzing the results, the researchers’ background and study involvement might have further introduced biases. With regard to interviewing, the conducting researcher (SW) transparently communicated the potential role conflict during the interviews and encouraged the interviewees to speak openly. Being a sociologist helped in eliminating professional role overlap with the care providers involved. As to the process of analysis, regular discussions and contrasting of coding and interpretations between SW and KM and within the COMET study team and the affiliated research institutions aimed at increasing awareness of potential biases due to study involvement and professional affiliation. However, one bias may be that both researchers closer aligned to the care providers’ and patients’ side than taking a systems’ approach, e.g. with a focus on cost-effectiveness.
As we explicitly decoupled the process evaluation from the main study results to prevent priming of participants’ experiences, our study results certainly only contribute one important column for the global evaluation of the COMET trial as an exemplary CSC model. While COMET is grounded in the German health care system and the Hamburg region, we believe the identified challenges and facilitating factors are of general relevance to mental health care. Difficulties in collaboration e.g. due to diverging and competing professional identities and health care settings, due to sector barriers, communication problems as well as general deficiencies in health care resources and remuneration structures also arise in health care systems differing from the German one and the care situation in Hamburg. Thus, our results can, at least to a certain extent, be transferred to other countries and regions, especially to care provided without co-location. Although the present study provides insights into collaboration in CSC models, further research is needed as to the sustainability of such models outside of trials, as this has been identified as challenge [
46].
Conclusions
The present process evaluation of the care providers’ perspectives in the COMET trial shed light on important aspects that have to be considered in future research and implementation of collaborative care models. While it is indispensable to take into account the main trial results and the patients’ perspective (to be published) to gain an overall picture, further research and practice recommendations can be deduced from the present results: 1) Future collaboration models should be implemented and examined in reasonable local boundaries, to allow for personal contact, as this has been one major benefit within the COMET trial. Moreover, further professional groups should be involved, as well by capitalizing on the potentials of tele-healthcare and digital communication. 2) Faster patient referral pathways, supported by a digital booking tool, have proven essential for improved patient care and a relief for PCPs in COMET. This should equally be fostered in future CS models. 3) Considering the prominent role of professional delineations and questions of power and competence that might impede on patient care, further research should be conducted on how to overcome these delineations, especially in settings without co-location, in favor of an interplay of competencies rather than opposition.
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