Introduction
In Canada, anxiety and depressive disorders are among the top five most frequently diagnosed long-term conditions.1 Prevalence of these common mental disorders (CMDs) is twice to three times higher among people with physical long-term conditions (LTCs), such as diabetes or cardiovascular diseases, than in the general population.2 The occurrence of these mental and physical health conditions is associated with morbidity and disability, resulting in decreased quality of life 3,4 and increased use of health services 5,6.
The collaborative care model (CCM) for the treatment of people with depression in primary care settings, built on Wagner’s Chronic Care Model, has been developed to improve quality of care.7The CCM involves a team of health care professionals, including a family doctor, a care manager and a mental health specialist working together based on an individualized plan developed from patient needs, preferences and evidence-based treatments.8 This model of care has been thoroughly studied and implemented over the past 20 years across the USA9 and in some European countries such as the Netherlands 10 or the United Kingdom.11
However, even though the CCM has been proven effective to improve the mental health status of a diverse clientele12 and cost-effective compared to usual care,13 there are still many barriers to its implementation. For example, challenges may be related to clinicians’ difficulty in understanding the role of each team member, to the care manager’s level of competency, or to the level of access to mental health resources.14-15-16 Adapting the CCM to local needs and involving stakeholders throughout the implementation process appears important according to two systematic reviews on enablers and barriers to CCM implementation.16-17 In general, an intervention that is defined and planned without being adapted to the organization is likely to encounter implementation difficulties, as this runs against the natural functioning of the organization.18
Models have been developed to guide the implementation of change in health care organizations, such as the Grol & Wensing implementation of change model.19 This model was developed incorporating a number of theories on implementation of innovations and change such as planned-change theories and determinants of effective implementation of change.19 It proposes seven dynamic steps that are interconnected and which can be conducted more than once depending on the context and emerging results: “1) Development of a proposal for change; 2) Analysis of actual performance; 3) Problem analysis of target group and setting; 4) Development and selection of strategies; 5) Development, testing and execution of an implementation plan; 6) Integration of changes in routine care; 7) Continuous evaluation and adaptation of the plan where necessary”.20 p.xviSteps one to four and part of step five (development of an implementation plan) refer to the pre-implementation phase and allow strategic planning of the change with stakeholders, i.e. people who are directly affected by the change of practice. Importantly, these steps can inform on targets for change, determinants of change, strategies to prioritize according to local needs, and resources and activities needed to implement change.20 Emerging results can then help researchers to model change, resulting in a better idea of what to measure when assessing the effectiveness of implementation strategies on patient outcomes or quality of care.
Even though it is a crucial stage, few studies have described the process and methods used to strategically plan the implementation of change21 and there is also little evidence available on the implementation of the CCM in primary care settings in Canada22. The purpose of this article is to present a case example of a process to plan the implementation of change based on CCM evidence for people with common mental disorders and physical long-term conditions in primary care settings, using the pre-implementation steps of the Grol & Wensing implementation of change model as a framework.