Three main sub-themes emerged from the analysis across the single-case study and the multi-practice study: 1) DCCM enablers, 2) DCCM barriers and 3) Who needs collaborative care? The relevance of target groups.
Access to “free” treatment and workload reduction
GPs in both studies were positive towards a new treatment model addressing the growing number of patients with mild/moderate depression and anxiety, as these patients are time-consuming:
“It would in fact be a relief to many general practices, no doubt about it, if you could [refer patients]” (GP, multi-practice study).
“I could easily give up those conversations [conversational therapy]…because we are under quite a pressure staff-wise, so it [treatment by a care manager] would be a really nice relief. If I had lots of time I might not give it [conversational therapy] up” (GP, multi-practice study).
Most GPs expressed frustration about limited referral options for these patients and long waiting lists for treatment by private practising psychologists. The care managers added that the DCCM meets a need in general practice for patients who are not sick enough for treatment in specialized psychiatric ambulatories. A care manager explained:
“There are certainly not any patients [included in the DCCM] with severe depression, and then they have no chance of being offered treatment in a psychiatric ambulatory. Alternatively, the GP should treat…and to my knowledge most GPs have done… these patients with conversational therapy, and now they have handed them over to the project [the DCCM] for a while” (care manager).
Improved access to treatment and “free” treatment were important enablers among GPs and a reason for the single-case GP to join the DCCM:
“I joined the project to have an offer to patients who cannot afford a private psychologist and who are not sick enough for treatment at the psychiatric hospital ambulatories” (GP, single-case study).
The DCCM also targeted another GP concern; the existing reimbursement structures for provision of conversational therapy to patients with mild/moderate anxiety and depression. Danish GPs receive reimbursement for conversational therapy only if the patient receives at least two consultations. If a patient does not return for a second conversational therapy consultation, the GP is not entitled to reimbursement for the time spent on the first consultation; this can have a negative impact on the motivation of some GPs:
“I allocate extra time and then maybe the problem is solved or the patient doesn’t show up [for the next appointment], so I don’t get the reimbursement for the extra time spent…so I think rather despondently that I won’t engage in that” (GP, single-case study).
The DCCM does not only accommodate workload issues concerning the many patients with mild/moderate anxiety and depression; it also tends to encompass the frustrations related to reimbursement structures.
Quality of treatment
In addition to workload issues, some GPs expected the CC treatment to improve the quality of care because the DCCM allowed more time for systematic cognitive conversational therapy. In the single-case study, the GP reported the impression that the care manager in fact improved the quality of care:
“Well, she [care manager] has more time, and I think she works more thoroughly than I do. I don’t do it as thoroughly” (GP, single-case study).
In line with this, a GP in the multi-practice study reflected on the advantages of collaborative care:
“It would be really nice to feel that they [care managers] are competent and hired directly to deal with this and to have allocated time slots, where this person [care manager] could offer half an hour... And this person [care manager] could reach some level of overview of our patients, and get some kind of knowledge about these patients and have a continuous relation to them…that would be fantastic, and it would take off some of the pressure” (GP, multi-practice study).
Most GPs across our studies agreed that the interest and expertise in mental health treatment vary immensely among GPs and that improved referral options would benefit both the GPs and their patients:
“When you open a referral option, most GPs who do not find it interesting to work with mental health treatment will hurry to refer [their patients]. That is great, because everybody would be happy… And not everyone [every GP] has the competencies required in this field, or an interest…” (GP, multi-practice study).
The lack of interest among some GPs combined with the need for improved quality in this field and the experience/knowhow of care managers could thus be another enabling factor for collaborative care.
Training and supervision by psychiatrist
GPs at the DCCM information meetings showed interest in the possibility for supervision and/or training by specialized psychiatrists. They especially requested brush-up courses on psychoactive drugs and regular supervision in peer groups lead by a psychiatrist. In the multi-practice study, GPs also stressed the importance of collaborating with a psychiatrist for specialised advice on patients who do not respond to the usual treatment in general practice. The same was expressed by the GP in the single-case study, but eight months after the DCCM launch she had not yet been introduced to brush-up courses or supervision by a psychiatrist.
The GPs’ need for upgrading their psychiatric competencies might be an enabling factor of the DCCM if a psychiatrist facilitates training and supervision.
Care managers as implementers
The care managers proved to be translators of the overall idea of the DCCM. This task was not a described standardized element of the DCCM, which left the care managers to pragmatic maneuvering. Observations of GP-care manager interactions and interviews with the two care managers indicated that the care managers aimed to facilitate a smooth implementation of collaborative care, but they also acknowledged the challenge of entering general practice as outsiders:
“…it is about how you enter general practice, you enter their territory, and you come as a guest. So you have to tread cautiously …” (care manager).
Approaching general practice in pragmatic ways and fitting the DCCM to the individual GP’s preferences supported the implementation of the DCCM. The care managers had to adapt to different appointment systems, lack of office space, different therapeutic approaches and varying levels of engagement because they worked in many different clinics. The care managers also adjusted to the priorities of the GPs. For example, the GPs were to complete standard questionnaires with the patients, but the care managers took on this task when this did not happen although it deviated from DCCM “protocol” to get things done and avoid conflict:
“We [the care managers] do take it [the workload of GPs] into consideration. Maybe it is overstated… I have defended this [doing the GP’s task] to myself by thinking that it is extremely important that we get started well and that we get to know each other, and that I don’t appear too rigid and too insisting” (care manager).
The flexible and pragmatic approach taken by the care managers enabled implementation of the DCCM. The ability to juggle GP needs and adapt DCCM elements to different organisations made the care manager an asset in collaborative care.
Organizational and practical barriers
The DCCM caused several logistic and organizational problems that (although simple) caused trouble in the implementation. First, the referral procedures were inadequately described:
“It caused me trouble. The first few times I just referred [the patient] to the psychiatric hospital with a note saying that this person wanted to participate in collaborative care, and then they declined because referral requires a scheduled time for consultation with the care manager…and I don’t think I have been properly informed about that” (GP, single-case study).
Second, there was lack of information about the practical procedures on how to obtain remuneration:
“We have these reimbursement options which I have tried to apply, and then they are rejected, apparently because I am not registered in the care manager project. Well. Who do I register with? So I just had to contact them again and claim to be registered in the project and then they accepted…I have contacted the project manager twice about this, and he hasn’t replied…we need some follow-up on the information meeting” (Single-case GP).
Third, the DCCM increased the GP workload as it required shared consultations with the care manager, coordination and booking of consultations, and setting up appointments for patients. It also proved difficult to organise a consultation room for the care manager:
“Well, there is all the hassle; everything I have attended…information meetings, meetings [with the care manager] here and…yes, making sure the consultation room is ready. There is a lot I have to do extra…” (GP, single-case study).
In line with this, a care manager stated:
“They don’t have a spare room, so there is a lot of logistics and planning in it for us as care managers. My calendar, the patient’s calendar and then the consultation room, the [psycho-education] classes, conferences. It is a huge logistic work. And some patients go to school and some go to work, which you must also show consideration for” (care manager).
In the follow-up interview, the GP in the single-case study concluded that she might not want to volunteer and invest the extra resources in a similar future collaborative care model.
The findings indicate that the DCCM was inadequately prepared; the project did not get off to a smooth start, and this challenged successful implementation and continuation of the intervention.
An important aim of the DCCM was to improve the cooperation and communication between primary and secondary care through facilitation by care managers. Although most GPs in both studies embraced the idea of collaboration with specialised psychiatry, several GPs at the recruitment meeting expressed a priori scepticism towards handing over their patients to care managers. Furthermore, some were reluctant to attend training courses facilitated by care managers. This a priori scepticism towards the role of care managers in cross-sectorial collaborative care can be interpreted as a mental barrier to the DCCM and as a sign of a lack of interprofessional respect. In line with this, a GP in the multi-practice study expressed a general frustration towards existing visitation procedures where psychiatric nurses assess whether a patient referred by a GP is eligible for specialized psychiatric care:
“It can be frustrating when you refer a patient who doesn’t respond to the treatment, and then it is a nurse who assesses the patient and rejects the patient without having a psychiatrist involved” (GP, multi-practice study).
The quote could be read as lack of confidence in the expertise of psychiatric nurses, but it also expresses a frustration in the GP towards what seems to be gatekeeping by psychiatric nurses when the GP needs assistance by a psychiatrist. This frustration was shared by most GPs in both the single-case study and the multi-practice study. Despite an a priori scepticism in some GPs, the GP in the single-case study expressed that her clinical cooperation with the care manager in the DCCM ran smoothly and that the care manager seemed to be competent. The care manager herself experienced a positive attitude towards her in most of the DCCM practices she collaborated with, and she found that the GPs actually welcomed interdisciplinary exchange:
“What I hear, at least from three of the GPs that I talked to, is simply a need for a professional back-and-forth; the dialogue, ‘I see the case [the patient] like this and this: How do you see it?” (care manager).
Despite the willingness in the GP to provide a professional back-and-forth, the DCCM set-up did not facilitate a closer cooperation according to the findings in the single-case study. Except for brief ad hoc exchanges of treatment plans and coordination of shared consultations, both the GP and the care manager considered it more as a transfer of the patient. In that sense, as also reported by the single-case GP, the collaborative care project facilitated only a shallow relationship across sectors and disciplines.
The GP stated:
“I don’t cooperate a lot with the care manager in the sense that we exchange experiences and stuff … I get to know the care manager a bit through the initial and last consultations. But proper exchange of knowledge and experience on how to handle these patients or sharing her tricks with me…that doesn’t really happen” (GP, single-case study).
Both care managers agreed. One care manager concluded:
“The way that our shared consultations worked meant that they actually had the characteristics of a transfer [of the patient] with the GP telling the patient, in my presence, that ‘I have told this and this [to the care manager] about your situation’” (care manager).
The other care manager said:
“…and my conclusion right now is that it is hard for me to see, in relation to these patients, why I should claim a need for a shared consultation” (care manager).
The care managers and the GP agreed that written communication would have been sufficient to exchange the necessary information and that treatment of patients by care managers could have been conducted in a psychiatric outpatient ambulatory, but the collaborative care part would then have vanished. One care manager explained:
“They [the patients] might as well get treatment in the ambulatory, but then there would be no collaboration with general practitioners” (care manager).
The GP in the single-case study acknowledged that increased cooperation across sectors was time consuming, and she was unsure if she would be willing to invest more time in it.
In addition to organisational and logistical issues, several other important barriers to the DCCM were identified: the unclear character and purpose of the cross-disciplinary cooperation, a priori scepticism in many GPs towards care manager-facilitated training, and limited actual exchange of knowledge and experience.
The single-case study revealed a number of organisational, practical, logistic and resource-related barriers to the DCCM when meeting the realities in general practice. The care managers were intended to provide treatment of patients in up to 10 general practices . This set-up challenged both coordination and logistics, and the care managers experienced a considerable waste of time when commuting between different general practices. Due to these barriers and the lack of capacity in specialized psychiatric care, the care managers doubted that the model would be sustainable beyond the project period:
“There wouldn’t be enough qualified nurses if you deploy this model everywhere. So I can’t imagine how this model should be implemented permanently in its current form. I really don’t” (care manager).
The GPs in the multi-practice study appreciated the potential of the DCCM to free time, but some also feared that it might “steal time” due to planning and coordination with the care manager. The care managers found it time-consuming to get the DCCM model started and running (also after the run-in period).
The logistical problems of finding a vacant consultation room for the care manager were also mentioned as a potential barrier to the sustainability of the proposed DCCM by GPs in the multi-practice study:
“It [treatment by care manager] should not be done here. Then they [the care managers] would have to be here all the time. Then they [the care managers] would need their own consultation room, or we should receive some kind of reimbursement, or we should rent out [the consultation room], and then we would have the trouble with administrating their booking of consultations and things like that. So… otherwise, I would be the one paying for the patients’ free treatment, and then we wouldn’t do it. It [collaborative care] has to be solved [done] somewhere else, I think…then it would be really great, but yes…they should create an ambulatory for it because it would be swarmed with patients” (GP, multi-practice study).the multi-practice study
One important barrier thus seems to be that the DCCM involved extra (rather than reduced) workload in general practice without compensating the GPs for this additional work.
Several barriers to the DCCM were experienced by the single-case GP and perceived by the GPs in the multi-practice study. Although the care managers played a central role in the treatment and collaboration related to the DCCM, none of the GPs in the multi-practice study requested elaborated cooperation with a care manager from specialised psychiatry for patients with mild/moderate anxiety and depression. The GPs seemed to expect benefits from collaborative care in terms of improved access to high-quality treatment rather than increased collaboration with external partners, including a care manager situated in the clinic. Consequently, the support gained by the DDCM was not considered to sufficiently justify the time spent.
Who needs collaborative care? The relevance of target group
DCCM enablers and barriers were partly related to the way that the GPs perceived mental healthcare for different patient groups, and how the GPs tended to divide these into categories according to the severity of the patients’ mental illness and their treatments needs.
When asked which of patients with mental health problems they found the most challenging to treat, the GPs (across both studies) referred to specific diagnoses, and they categorised the patients into two main groups based on the severity of conditions: 1) a large group of patients with mild/moderate mental health problems and 2) a small group of patients with severe mental health problems (e.g. severe depression, schizophrenia and other psychotic conditions) and higher risk of somatic comorbidity and complex health problems:
“There are not as many patients with schizophrenia as patients with anxiety and depression so it is a matter of prioritising resources. The schizophrenic patients are left more to themselves; they are a more vulnerable group who rarely consult their GP. Patients with anxiety and depression consult their GP regularly. And often they have relatives who support them, whereas the schizophrenic patients are more socially isolated” (GP, multi-practice study).
The GPs considered treatment of mild/moderate mental health conditions to be a central GP task, but the number of patients is increasing, and the GPs do not have the capacity to handle the volume of patients. The GPs emphasized that the complexity of the mental/somatic/social problems in patients with severe mental health conditions makes them an especially vulnerable group; they are the most challenging to care for in general practice and have the highest need for improved treatment.
“Where are the schizophrenic patients now? The number of hospital beds have been cut back, they are discharged, and they disappear into nothing, and we are not in control of them…it happens too often” (GP, multi-practice study).
When asked about the potential of a collaborative care model that integrates psychiatric and general practice treatment, the GPs agreed that the patients with severe mental health problems and somatic comorbidity have the highest need for cross-disciplinary and collaborative treatment. The complexity of health conditions in these patients calls for new ways to ensure integrated mental healthcare that meets their somatic, psychiatric and social needs, whereas the GPs did not see a need for enhanced collaboration with specialised psychiatry on patients with mild/moderate mental problems. For this patient group, they requested a fast track to high-quality treatment in cases when usual care fails. This discordance between the target group of the DCCM and the actual and perceived needs of collaborative care suggests a major motivational barrier for successful implementation of the DCCM.