Background
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What are the key components needed for an intervention for people living with mental-physical multimorbidity?
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How can motivational interviewing inform the model of care?
Method
Theory-informed development
Review of the clinical guidelines
Group interviews
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What do primary care nurses describe as the challenges or difficulties of working with multimorbid patients?
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What do primary care nurses describe as helpful approaches or clinical skills for working with multimorbid patients?
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What role do primary care nurses see for motivational interviewing in working with people with multimorbidity?
Intervention development and description
Results
Theory informed development
Review of the clinical guidelines
Elements of intervention | Clinical Guideline or Cochrane review offering specific support for clinical focus area | Planned approach to operationalising recommendations for intervention |
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Clinical focus elements | ||
Patient identified priority areas | Amer Ger Soc (2012)a Muth et al. (2014)b Naylor et al. (2016)c Smith et al. (2012)d | • Provide clinicians with information about the patient’s priority areas based on survey response prior to initial appointment. • Priorities to be discussed, affirmed or altered collaboratively at the initial appointment • Planning at initial assessment and follow-up sessions to directly address patient priority areas, and this approach to be supported by documentation templates providing space for priority areas, as well as template to include helpful questions in establishing priority areas |
Mental health focus | Muth et al. (2014)b Naylor et al. (2016)c | • Intervention materials to include evidence-based behavioural targets for improving mood and well-being in people experiencing depression • Evidence-based priority areas to include: mood, anxiety, concentration, self-image, thoughts of death and concentration, health, appetite, interest, sleep, energy |
Support for lifestyle behaviour change | Naylor et al. (2016)c Smith et al. (2012)d | • Specific priority areas relevant to lifestyle behaviour change include: health, appetite, interest, sleep, energy • Intervention to include collaborative planning with patient to identify planned changes to behaviour and ongoing monitoring, review of progress and revised planning • MI communication strategies to focus on and strengthen the patient’s reasons for making changes. |
Emphasis on clinical consultation skills | Amer Ger Soc (2012)a Naylor et al. (2016)c | • All nurses participate in 2 days of training, including 1 day focused on motivational interviewing skills. • Development of support materials to reinforce MI skills. • Intervention summary plans to incorporate open questions in the templates; and intervention manual to include examples of patient-centred clinical notes to support implementation |
Organisation of delivery elements | ||
Integrated into routine care | Naylor et al. (2016)c Smith et al. (2013)d | • Program to be co-located in existing GP practices. Patients to have option of face-to-face or phone follow up sessions to promote flexibility and minimize treatment burden. |
Appointments longer than GP consultation | Naylor et al. (2016)c | • Initial appointments planned to be up to 1-h duration, with follow up appointments up to 30 min duration. • Intervention to be delivered by primary care nurses to enable longer consultations |
Scheduled review appointments | Amer Ger Soc (2012)a Muth et al. (2014)b | • Intervention to consist of 8 sessions over approximately 12 weeks. All sessions to be scheduled collaboratively with the patient. |
Enhanced communication between care providers | Muth et al. (2014)b Naylor et al. (2016)c | • With patient consent, nurses to liaise with and share plans with GPs and other health professionals involved in the patient’s care. |
Group interview analysis
Participants
Group 1 Mean (SD) n = 3 | Group 2 Mean (SD) n = 3 | Overall Mean (SD) n = 6 | |
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Age | 53.00 (6.24) Range: 46–58 | 48.00 (5.57) Range: 42–53 | 50.5 (5.96) Range: 42–58 |
Years of practice since graduating | 33.00 (8.19) Range: 24–40 | 23.67 (3.21) Range: 20–26 | 28.33 (7.55) Range: 20–40 |
Confidence working with people with chronic conditions | 8 (1) Range: 7–9 | 8.67 (1.15) Range: 8–10 | 8.33 (1.03) Range: 7–10 |
Confidence working with people with mental health issues | 6.67 (3.21) Range: 3–9 | 7.33 (1.15) Range: 6–10 | 7.00 (2.19) Range: 3–9 |
Confidence working with people with multimorbidity | 7 (1) Range: 6–8 | 8 (0) Range: 8 | 7.5 (0.84) Range: 6–8 |
Analysis of group interviews
Relationship of the group interview analysis to the proposed theory and review of clinical guidelines
Issue identified by nurses | Intervention elements designed to address issues identified by nurse |
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Helpful documentation can support implementation | • Documentation all written with the patient at the centre of care, eg sections included “What I want to achieve” and “How I want to achieve it”. • Plans and session summaries included patient priority areas, and a brief review of progress, emphasising achievements and changes made, as well as revised plans. PHQ-9 also included in documentation and shared with patient. |
Communication between providers is important | • Protocol for intervention included all plans and session summaries to be shared with patient, GP, and any other health professionals nominated by the patient. • Nurses to communicate with GPs via email after each session. • Any concerns raised with GP, and risk assessment supported by a risk assessment protocol. |
Nurses need practice and prompts to develop these skills. | • MI prompts included as questions on the documentation templates. • MI Pocket Guide developed as a brief summary and prompt for MI skills. • Manual for nurses to provide a range of examples of verbal and written responses in an MI-consistent way. |
Intervention description
Target-D Collaborative Care WHY: To address the need for an intervention to support people living with multimorbidity, in particular mental-physical multimorbidity. The key proposed mechanisms of the intervention, underpinned by Theory of Planned Behavior and motivational interviewing are to engage patients, focus intentionally on what is important to them, and empower them to make changes through a structured process of goal-setting, review, and individualised referral to support services and resources as appropriate. WHO: Patients in primary care waiting rooms complete an initial assessment and their scores indicate the likelihood of severe depression at 3 months. GPs are actively involved in the collaborative care process which is embedded in GP practices. Target-D nurses were all registered nurses. WHAT: Initial assessment: The initial assessment tool is an evidence-based algorithm to determine which patients are likely to experience severe depression in 3 months’ time.aThe assessment also requires participants to select priority areas that are important to them from evidence-based areas for behaviour change to support improved mood and wellbeing, including: mood, anxiety, concentration, self-image, thoughts of death, concentration, health, appetite, interest, sleep, and energy. Initial collaborative care consultation: Target-D nurses use MI to engage participants and to collaboratively set goals and develop a written action plan focused on participant’s priority areas. Monitoring and review: Subsequent sessions continue the focus on participant priority areas, and aim to empower participants through collaborative review, providing referral or resources, and reinforcement for changes. Participants choose between face-to-face and telephone sessions. Follow up: After each session participants receive a personalised and reinforcing email and a copy of the plan. Plans are shared with the GP and health care team. Templates and plans are included in the Target-D handbook to assist Target-D nurses to write in a way that emphasises patient perspectives and supports self-efficacy. FREQUENCY AND DURATION: The Target-D Collaborative Care intervention provides up to 8 sessions per patient. The initial session is designed to be a longer session, proposed to last approximately 60 min, with follow up sessions planned as shorter sessions of approximately 15–30 min duration. The first four sessions are conducted weekly, and the final four sessions are conducted fortnightly. The total duration of the intervention is approximately 3 months. TAILORING: The intervention is driven by the priority areas identified by participants. The intervention is flexible to participant preference for face-to face or telephone sessions. Referrals to other service providers or resources are tailored to the participant’s goals and preferences. |