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.