Background
The collective action and interactions of patients, professionals and others are governed by four factors. We have derived questions from these factors as follows: | |
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(i) Interactional workability: This refers to how work is enacted by the people doing it. A complex intervention will affect co-operative interaction over work (congruence), and the normal pattern of outcomes of this work (disposal). | How does collaborative care for depression (CCD) impact on basic communication, clinical care and treatment at the level of patient and professional? |
(ii) Relational integration: This refers to how work is understood within the networks of people around it. A complex intervention will affect not only the knowledge required by its users (accountability), but also the ways that they understand the actions of people around them (confidence). | How does CCD impact on the way that health professionals relate to each other? Does it seem to be the right thing to be doing? It is perceived as valid and/or useful? Who needs to be involved in the work? How do we inform them and link with them? |
(iii) Skill-set workability: This refers to the place of work in a division of labor. A complex intervention will affect the ways that work is defined and distributed (allocation), and the ways in which it is undertaken and evaluated (performance). | Does this mean health professionals learning new skills or doing things differently? Is there a person available with the right set of skills to implement CCD? Does CCD challenge professional autonomy over working practices? Does it impact on case load and allocation of work? |
(iv) Contextual integration: This refers to the organizational sponsorship and control of work. A complex intervention will affect the mechanisms that link work to existing structures and procedures (execution), and for allocating and organizing resources for them (realization) | Who has the power to make CCD happen? Does the system want it to happen? How can we divert resources to it? |
Brief description of the collaborative care trial
Aims of this study
Methods
Before the trial
Sample
Data collection
After the trial
Sample
Data collection
Analysis of the data for this paper
Results
Interactional workability of collaborative care
How does collaborative care for depression impact on basic communication, clinical care, and treatment at the level of patient and professional?
Relational integration
How does Collaborative Care impact on the way that health professionals relate to each other?
Who needs to be involved? How do we inform them and link with them?
Does it seem to be the right thing to be doing? Is it perceived as valid and/or useful?
Skill-set workability
Does this mean health professionals learning new skills or doing things differently? Is there a person available with the right set of skills to implement Collaborative Care?
Does Collaborative Care challenge professional autonomy over working practices? Does it impact on case load and allocation of work?
Contextual integration
Who has the power to make collaborative care for depression happen? Does the system want it to happen? How can we divert resources to it?
Discussion
The value of the NPM
Lessons for collaborative care trials
Further lessons for wider implementation of collaborative care
Strengths and weaknesses of the study
Summary
Appendix 1: Optimizing the interactional workability of collaborative care
'Work' needs to address
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Engaging the patient.
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Explanation of the systematic nature of approach to care.
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Alliance building- easier if first assessment is face-to-face.
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Explaining the use of the structured approach to assessment of severity.
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Collaborative style of working.
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Specific communication and confidentiality issues raised by telephone working.
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Postal preparation for the telephone session.
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Negotiation of difficult issues raised by ending. Dealing with ambivalence and potential for dependence.
Appendix 2: Optimizing the relational integration of collaborative care
'Work' needs to address
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Clarity of arrangements for liaison between patient, PCP, and case manager.
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Clarification of the roles and responsibilities of the specialist supervisors in relation to the PCP
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Adjusting the depression focus of the protocol in research practice to the reality of co-morbidity issues in primary care practice. Particularly an issue for wider implementation.
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Not only developing the evidence base but educating other key professionals in the wider network about the evidence base for collaborative care.
Appendix 3: Optimizing the skill-set workability of collaborative care
'Work' needs to address
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Recognition within organisations that there is a workforce that is being specifically trained for this task.
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Opportunities for other workers to train in these skills if they wish to.
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Development of comprehensive working protocols to manage risks.
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Appropriate supervision and liaison arrangements.
Appendix 4: Optimizing the contextual integration of collaborative care
'Work' needs to address
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Management practice within the organisation- to facilitate new ways of working.
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Effective service planning.
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Leadership within the local health economy.
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Developing the business case by policy leaders and managers.