Background
Collaborative care component | Expression in the PARTNERS model |
---|---|
1. An underpinning conceptual model of collaboration | Wagner’s Chronic Care Model elements: protocol-based planned care, the development of case management roles, support for patient self-management, expert consultation and decision support, shared information CHIME framework for personal recovery [11] (recovery processes to be targeted by the direct patient support component): connection, hope, identity, meaning, empowerment |
2. Identification of patients: method | Eligible service users identified through screening of records against inclusion criteria |
3. Identification of patients: setting | Primary and secondary care |
4. Provider integration: | Specialist mental health worker (known as a care partner) is allocated from local secondary care community mental health team and based in GP surgeries. |
5.Multi-disciplinary working | Care partner works alongside GPs and other primary care practitioners, under the supervision of a qualified mental health worker (from any mental health profession) based in local secondary care community mental health team, with access to consultation from psychiatrists if not available through supervision. |
6. Systematic communication between providers | Care partners record information in shared records, including progress notes and care plans. Co-location supports face to face communication between care partners and primary care practitioners. |
7. Case management | Care partners co-ordinate care, liaising with other providers (e.g. primary care practitioners, community mental health teams, community organisations) to ensure service users’ needs are met. |
8. Study protocols / treatment algorithms | Intervention manual, describing the principles and approaches which should be adopted by care partners while responding flexibly to individual need. |
9. Systematic monitoring / follow up | Regular review of service users at individually negotiated intervals, varying in intensity according to need, with a minimum of telephone contact three times a year and an expectation of more frequent face to face contact as standard. Routine use of standardised measures to monitor mental health. |
10. Pharmacological intervention | No specific intervention, unless identified as a personal goal by the service user, leading to the development of individual action plans, which could include psychiatric review. |
11. Psychological intervention | Care partner provides coaching to enable the service user to identify personally meaningful goals, individualised action plans and relevant resources and to become an active participant in managing their own health and wellbeing. |
12. Education for mental health / primary care providers | Two-day training in the intervention as described in the manual provided to care partners and supervisors. |
13. Patient education / promoting self-management | Care partner provides information and uses motivational interviewing approaches to encourage service user to identify and work towards personal goals related to improved physical health and mental wellbeing. |
14. Shared decision making with patients | Care partner adopts a collaborative style of interaction with service users, engaging with them as an equal in the service of the aim of achieving service user empowerment, as specified by the CHIME framework. |
Figure 1 represents the way in which the PARTNERS intervention operates at multiple levels with the outcomes derived from one level becoming intervention resources for the next level. In the diagram, mechanisms are broken down into the resources provided and the anticipated reasoning and reactions of the relevant actors. It is hypothesised that engagement with leadership of primary and secondary care services will lead to agreements that specialist mental health workers will be placed into primary care teams, where they will deliver care to people with a diagnosis of bipolar, schizophrenia or other psychosis who are patients of that practice, according to the PARTNERS model. These agreements are operationalised in the manual and through training delivered to care partners and supervisors. The manual and training act as resources for care partners and supervisors, supporting them to develop the knowledge and skills required to fulfil their respective roles. For supervisors, this is the provision of regular, protocolised supervision, in which they review whether the care partner is delivering the intervention as intended and provide support and guidance to ensure fidelity to the model. In turn this serves to further develop the care partners’ knowledge and skills. The care partners’ role consists of a range of activities directly with service users and communication with other people and agencies who can provide support for service users’ health and wellbeing. The support provided by care partners directly to service users is hypothesised to increase their belief in themselves and their ability to control their health and their lives, leading to an increase in service user behaviours which are likely, in turn, to lead to improved health. These include actively engaging themselves with other people and agencies who can provide support for their health and wellbeing. Successfully changing behaviour is also thought to further contribute to the service users’ confidence, creating a virtuous cycle of ongoing improvement. Care partner liaison with other sources of support is thought to lead to greater understanding in these individuals of how they can best support the service user in improving their health and wellbeing and thus the provision of support that will enable the service user to make desired changes. It is also thought to broaden care partners’ awareness of health and wellbeing needs that service users might have and the range of supports available to meet these. These mechanisms are thought to operate in contexts, which include the pre-existing characteristics of services, such as cultures and leadership style, and individuals, such as previous experience and attitudes. Thus a care partner may be more able to understand the intervention and deliver it as intended if they have previous training in coaching or a service user may be more likely to respond positively to the coaching approach if they are ready to change. |
Aims
Methods
Design
Intervention
Participants
Procedure
Site | Care partner interviews | Service user interviews | Supervisor interviews | Family carer interviews | GP interviews | Other primary & secondary care workers interviews | Intervention sessions | Service user tape assisted recall interviews | Care partner tape assisted recall interviews | Total |
---|---|---|---|---|---|---|---|---|---|---|
A | 1 | 6 | 1 | 2 | 2 | 3 | 1 | 1 | 1 | 18 |
B | 2 | 2 | 2 | 0 | 1 | 0 | 2 | 1 | 1 | 11 |
C | 1 | 6 | 1 | 3 | 1 | 3 | 5 | 5 | 5 | 30 |
Total | 4 | 14 | 4 | 5 | 4 | 6 | 8 | 7 | 7 | 59 |
Data analysis
Results
Service user | Family Carer | Practitioner | |
---|---|---|---|
Site (n) | |||
A | 6 | 2 | 7 |
B | 3 | 0 | 3 |
C | 7 | 3 | 6 |
Gender (%) | |||
Female | 25 | 80 | 75 |
Male | 75 | 20 | 25 |
Age (mean, sd) | 53.3 (11.04) | ||
Diagnosis (%) | |||
Schizophrenia | 44 | ||
Bipolar | 56 |
Aim 1. Evidence of whether the intervention as delivered matched the model
Delivered as intended | Not delivered as intended |
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1. An underpinning conceptual model of collaboration | |
The PARTNERS model included manualised and planned care, a case-manager, support for self-management through coaching, making specialist mental health workers readily available to primary care workers and recording in shared records. The CHIME framework was included as a specific focus of the intervention. | |
2. Identification of patients: method | |
Service users were identified from records and discussion with secondary care staff | |
3. Identification of patients: setting | |
Service users were identified in both primary and secondary care settings. | |
4. Provider integration | |
In two sites: | In one site: |
• Care partners maintained allocated time to carry out PARTNERS role • Primary care services accommodated the care partner’s needs | • care partner required to return to secondary care role • primary care services did not give care partners access to necessary resources (e.g.: rooms, access to IT) |
5.Multi-disciplinary working | |
In one site: | In all sites: |
• supervision took place routinely | • limited evidence of integration into primary care teams |
In all sites: • access to psychiatric consultation was available | In two sites: • supervision was not delivered consistently |
6. Systematic communication between providers | |
In all sites: | In all sites |
• a few examples of care partners making helpful entries in records, making appropriate requests to GPs and attending practice meetings | • very limited evidence of recording in shared records • very limited evidence of interaction between care partners and primary care teams |
7. Case management | |
In all sites: | |
• evidence of care partners liaising with other providers in response to goals identified by service users or change in mental health | |
8. Study protocols / treatment algorithms | |
In all sites | |
• care partners and supervisors were aware that the manual should guide care and evidence that they accessed the manual | |
9. Systematic monitoring / follow up | |
In one site: | In one site: |
• repeated measures used consistently | • no evidence that repeated measures used • lack of regular follow up by care partner |
In two sites: • regular follow up provided | In one site: • repeated measures used but not in a way that was consistent with the ethos of the model |
In one site: • uncertainty about whether variation in intensity could include duration as well as frequency of contact | |
10. Pharmacological intervention | |
In all sites | |
• evidence that this had been discussed as a possible personal goal and psychiatric consultation sought where relevant | |
11. Psychological intervention | |
In one site: | In all sites: |
• coaching approach used to a large extent | • resources provided in the intervention manual to support coaching processes were rarely used |
In two sites: • very limited evidence of coaching approach being used | |
12. Education for mental health / primary care providers | |
In all sites: | |
• training provided | |
13. Patient education / promoting self-management | |
In one site: | In two sites: |
• motivational approach used to a large extent | • very limited evidence of motivational approach being used |
14. Shared decision making with patients | |
In one site | In all sites: |
• collaborative style of interaction largely present between care partner and service user | • service user guide intended to support service user participation not widely used |
In two sites: • very limited evidence of a collaborative style of interaction between care partners and service users |
Aim 2. Barriers and facilitators to delivering the model as intended
Barriers | Facilitators |
---|---|
Systematic communication | |
• Primary care service difficult to access • Care partner passive approach • Lack of support for care partner • Lack of service user interest | • Primary care service hospitable • Care partner pro-active and flexible approach • Care partner seeks support • Service user motivated to access support |
Coaching and goal setting | |
• Beliefs unsupportive of goal setting • Coaching incongruent with care partner style • Lack of supervision in use of coaching • Service user not motivated to change | • Goal setting valued • Coaching congruent with care partner style • Availability of supervision in use of coaching • Service users motivated to change |
Supervision
| |
• Lack of supervisor availability • Lack of supervisor understanding of model • Lack of awareness of need for change in care partner’s practice | • Supervisor makes themselves available • Supervisor understands model • Awareness of need to support care partner’s development |
Systematic communication
the manager…was very welcoming and introduced me to as many people as possible and… assigned a – I think she’s an admin worker or something, to me, so if I have any problems I just go to M. and M. does everything, and it’s great. [care partner 3]
in [name of surgery] I feel that it’s kind of in process now, it’s working, people are turning up and it’s almost like, well, do I need to do something? People are aware that I’m there, but I don’t feel that they have the quality understanding of why I’m there [care partner 3]
I can’t remember him saying that there was ever a particular issue? Not one, maybe, that he brought to supervision. [supervisor 2]
If I need to see me GP about health problems, I just go to me GP, I don’t involve [name of care partner]. [service user 1]
Coaching and goal setting
the goal-oriented approach for me is the crucial factor [service user 11]
I was just thinking about sometimes allowing the sessions to just be, because whilst there is an agenda, … of the coaching… sometimes I’ve found people don’t want to necessarily be coached, but they want to come along to the sessions [care partner 3]
To me, me getting [name of service user] and taking her physically and saying ‘Come on, [name of service user]’ and if I have to ‘There, there’ and wrap her up in cotton wool for a little bit, I’ll know the job was done and dusted then… I’ll know if she’s safe. [care partner 1]
I was getting meself bogged down …and I’d go to me manager and I’d say …‘ I need help here’, and it was like ‘Read your manual’ and I felt like saying [shouts] ‘You read the manual!’ [care partner 1]
some people have already set their own goals, they’ve been very good… very insightful into their own difficulties … just thinking of somebody that I’m working with at [name of surgery], she’s been very good at planning what she needs to do to improve her quality of life [care partner 3]
Supervision
we took on the single point of access team, recovery team as well as the crisis team, so my role sort of really expanded. So I feel really bad because I didn’t apply myself the way I probably should have done [supervisor 1]
I know he’s busy [care partner 1]
the manuals are on the table but they’re closed because – I know how we’ve been working over time and I understand the model [supervisor 3]
what I like is supervisions where people are challenging me and… giving me ideas of how I can improve upon things… rather than saying ‘Oh yeah, it’s really great’ [care partner 3]
Aim 3. Additional support for implementation likely to be required in the main trial
Actions to facilitate systematic communication between care partners and primary care practitioners
-
A link person to be identified within the primary care team, who will contribute to a local needs assessment, clarifying the most effective strategies for the care partner to communicate with the team about their work.
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Regular contact between researchers and care partners to ensure these strategies are being used and identify any concerns, and regular contact with the practice link person for problem-solving.
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The supervision protocol to be amended to include reviewing communication with primary care practitioners and providing support for developing communication strategies.
Actions to facilitate delivery of coaching and goal setting
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Revisions to care partner and supervisor manual and training, clarifying that goals can be psychological as well as practical and may include addressing the need for ongoing emotional support.
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Revisions to care partner and supervisor manual and training to provide clearer examples of coaching approaches and more opportunities for care partners and supervisors to practice through role play.
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Additional follow up training, in which care partners reflect on audio-recordings of their own work, together with supervisors to support learning from practice.
Actions to facilitate delivery of supervision
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Clear, negotiated agreements with secondary care service leadership about supervisors’ time commitments and regular contact between researchers and supervisors and researchers and service leadership for progress checking and trouble shooting.
-
Follow up training focussed on audio recordings of care partners’ practice, to encourage critical self-refection and support supervisors engaging care partners in detailed discussion of their work.
Aim 4. Comparison of perceived effects to the programme theory
Physical health
I can see that one patient that did come to see… my colleague, he was able to focus on his shoulder and his other thing that he’d come about and not try to do everything all at once. ‘Cos the danger is, you see a patient who’s on those sorts of drugs, you think ‘Oh god, I really need to think about their mental health’ and ‘Oh my god I need to check they’re not seeing things or they’re not in danger’, and then… there’s no time to look at stuff like stopping smoking or what their blood pressure might be [GP 4]
it’s also having that wider perspective of kind of interest… looking at… physical history, which I wouldn’t normally have access to those kind of records [care partner 3]
the other week she [care partner] was explaining that… I should have been having more… heart checks and stuff with the medication I’m on…and that’s the only thing that is a little bit weak, ‘cos I only had my first ever ECG [electrocardiogram]… a couple of weeks ago, and that’s ‘cos I asked for it. [service user 12]
Quality of life and CHIME framework outcomes
it’s giving me the confidence to get back out on the tightrope knowing that there’s safety net underneath me [service user 11]
we take the dog over there and we walk around the park a couple of times and I come home and I feel, yeah, I've got out and that's an achievement. Where beforehand I would have thought, ooh, no, no, I just can't do that. [service user 7]
Stability of mental health
there was a sense that [name of service user] felt that we were in a comfortable space, a comfortable environment for him to be able to talk about… he said that he could have bizarre, dark thoughts at times in the past. And I guess it’s a place that we can talk through those and then kind of – we can explore whether it’s something that’s out of the ordinary or whether it’s just kind of eccentric feelings, views, thoughts or whatever, to talk those things through [care partner 3]
even though I find putting a number on it is quite hard, but at the same time it gives you that general score of where you are… you might be depressed, but you're not having bad thoughts, you're not kind of not confident but you don’t need to worry [service user 12]
links to the psychiatrist, that’s been pretty good, ‘cos there was somebody …whose medication had been changed around and as a result she’d become a lot less motivated … so I spoke with a psychiatrist here, ‘cos I knew that she was going to be meeting as an outpatient, um, to see what their thoughts were about medication, and they’ve changed it back and she’s very pleased about that [care partner 3]