Step 1. Develop a proposal for change with stakeholders
Before proposing a change to stakeholders, a literature review on the innovation to be implemented was needed to understand its characteristics.23 The CCM (and the role of the care manager) was our evidence-based practice to improve the role of primary care nurses and collaborative care in FMGs. We identified the main characteristics of the CCM, i.e. components, professional activities or tasks involved in the CCM, factors that might influence its implementation and related outcomes.8,16,17 A scoping review was conducted to explore a specific aspect of the CCM: challenges of adopting the role of the care manager by primary care nurses.14 We also identified key interventions and materials on the CCM to prepare the implementation of change.
Among seminal publications in the field, we included the first large randomized controlled trial of treatment for depression that took place in the USA: Improving Mood-Promoting Access to Collaborative Treatment (IMPACT).24,25 Since then, IMPACT has been widely studied and adopted in many other countries, and a team of researchers at the University of Washington Advancing Integrated Mental Health Solutions (AIMS) Center developed tools to help researchers and managers implement the CCM. For instance, they created a checklist to evaluate the principles and main tasks (professional activities) of the CCM and published a full description of the care manager job.26,27
The review of the literature also helped to plan the methodology, such as identifying which type of participants should be recruited and it facilitated the development of data collection tools. Interview guides for each type of participant (patients, family doctors, primary care nurses, and other primary care providers) were developed to analyze actual practices and challenges to collaborative practice for people with CMDs and LTCs in FMGs. The three interview guides were respectively tested and reviewed by the research team with a patient partner, a primary care nurse and a psychiatrist not otherwise involved to the study.
To ensure feasibility of the project, we needed the collaboration and support of the Nursing Directorate at the regional hospital centre where the project was conducted. From January 2017 to September 2018, the principal investigator met with nurse managers of the Nursing Directorate twice to propose an improvement in nursing and collaborative practices for people with CMDs and LTCs in FMGs. The first meeting was to present a proposal for change based on previous studies.28,29 The second meeting was to confirm their interest in changing practices and to identify potential FMGs that might be of interest in the study. Three FMGs were targeted.
FMGs are organizations that are distinct from the hospital centre and are led by family doctors. Thus, we contacted the family doctors responsible for targeted FMGs by e-mail, including a one-page summary of the project describing the goal, staff involvement and timeline. When family doctors manifested their interest in the study, a face-to-face meeting was organized to present the project. A total of three urban FMGs were recruited (see Table 1).
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Insert Table 1
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In each FMG, health care professionals involved in the care of people with CMDs and LTCs were invited to participate in the study (e.g. nurse, family doctor, psychologist, social worker). With regard to patients, we asked recruited primary care nurses to identify one patient (adult) with at least one LTC and depression or anxiety. Identified patients were then individually contacted by a member of the research team to explain the project and obtain informed consent.
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Insert Table 2
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Within each FMG (n=3), a local working group was created, including at least one primary care nurse and one family doctor. They were involved to discuss the gap in their practices as well as to select and adapt strategies. The participant recruitment process for the working group differed between FMGs as we adapted our method to local preferences and procedures. In general, leaders of the group or those who were identified as champions in mental health care by their colleagues were involved in the working group. Moreover, a nurse manager at the regional hospital centre was also invited to attend the first meeting in each FMG. The number of participants involved in the first meeting of each working group ranged from 3 to 8 participants.
Finally, an advisory committee was created to counsel the research team on potential strategies to implement a change of practice based on the provincial and local context and to contribute to knowledge mobilization among FMGs. Members of the committee were invited based on their collaborative care expertise in primary care of people with CMDs and LTCs. This committee included 2 patient partners with a history anxiety or depression, and at least one LTC, who received primary care services for their mental and physical health problems. Other committee members included 3 researchers in the field of collaborative mental health care and nursing, 1 nurse manager, 1 family doctor, 1 primary care nurse, 1 psychiatrist, and 1 psychologist. Most of the participants were from different regions across the province of Quebec (n=4) except for one who was in another Canadian province (Ontario). However, the majority of experts (n=6) were from the region where the project took place.
In January 2019, an initial meeting with the Advisory Committee was held to share current CCM evidence and to discuss the feasibility of implementing main components of the CCM in FMGs. Throughout the process, the first author also met individually with certain members of the Advisory Committee to further address specific issues mentioned during the meeting such as primary care nurse training, the role of the psychiatrist, population-based care and mental health outcome measures.
Discussion on lessons learned. This step was beneficial to the development of a collaboration with nurse managers at regional hospital centres and with the leaders of each FMG, to initiate a reflection on the challenges to implementing the CCM in FMGs and to further our understanding of the CCM. The primary activity, which took almost a year to carry out, was to engage a variety of stakeholders in the project. In order to optimize stakeholder engagement, it is important to have a flexible agenda, to adapt communication methods to individual preferences, to simplify and synthesize scientific information as much as possible, being clear on the type of involvement and human resources needed.