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Brinck-Claussen UØ, Curth NK, Christensen KS, Davidsen AS, Mikkelsen JH, Lau ME, Lundsteen M, Csillag C, Hjorthøj C, Nordentoft M, Eplov LF. Improving the precision of depression diagnosis in general practice: a cluster-randomized trial. BMC FAMILY PRACTICE 2021; 22:88. [PMID: 33962564 PMCID: PMC8105936 DOI: 10.1186/s12875-021-01432-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Methods to enhance the accuracy of the depression diagnosis continues to be of relevance to clinicians. The primary aim of this study was to compare the diagnostic precision of two different diagnostic strategies using the Mini International Neuropsychiatric Interview (MINI) as a reference standard. A secondary aim was to evaluate accordance between depression severity found via MINI and mean Major Depression Inventory (MDI) sum-scores presented at referral. METHODS This study was a two-armed, cluster-randomized superiority trial embedded in the Collabri trials investigating collaborative care in Danish general practices. GPs performing case-finding were instructed always to use MDI when suspecting depression. GPs performing usual clinical assessment were instructed to detect depression as they would normally do. According to guidelines, GPs would use MDI if they had a clinical suspicion, and patients responded positively to two or three core symptoms of depression. We compared the positive predictive value (PPV) in the two groups. RESULTS Fifty-one GP clusters were randomized. In total, 244 participants were recruited in the case-finding group from a total of 19 GP clusters, and 256 participants were recruited in the usual clinical assessment group from a total of 19 GP clusters. The PPV of the GP diagnosis, when based on case-finding, was 0.83 (95% CI 0.78-0.88) and 0.93 (95% CI 0.89-0.96) when based on usual clinical assessment. The mean MDI sum-scores for each depression severity group indicated higher scores than suggested cut-offs. CONCLUSIONS In this trial, systematic use of MDI on clinical suspicion of depression did not improve the diagnostic precision compared with the usual clinical assessment of depression. TRIAL REGISTRATION The trial was retrospectively registered on 07/02/2016 at ClinicalTrials.gov. No. NCT02678845 .
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Affiliation(s)
- Ursula Ødum Brinck-Claussen
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| | - Nadja Kehler Curth
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark.
| | - Kaj Sparle Christensen
- Research Unit for General Practice, Institute of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Annette Sofie Davidsen
- The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Oester Farimagsgade 5, Postbox 2099, 1014, Copenhagen K, Denmark
| | - John Hagel Mikkelsen
- Mental Health Center Frederiksberg, Nordre Fasanvej 57-59, 2000, Frederiksberg, Denmark
| | | | | | - Claudio Csillag
- Mental Health Center North Zealand, Dyrehavevej 48, 3400, Hilleroed, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| | - Lene Falgaard Eplov
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
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Curth NK, Brinck-Claussen UØ, Hjorthøj C, Davidsen AS, Mikkelsen JH, Lau ME, Lundsteen M, Csillag C, Christensen KS, Jakobsen M, Bojesen AB, Nordentoft M, Eplov LF. Collaborative care for depression and anxiety disorders: results and lessons learned from the Danish cluster-randomized Collabri trials. BMC FAMILY PRACTICE 2020; 21:234. [PMID: 33203365 PMCID: PMC7673096 DOI: 10.1186/s12875-020-01299-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/26/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Meta-analyses suggest that collaborative care (CC) improves symptoms of depression and anxiety. In CC, a care manager collaborates with a general practitioner (GP) to provide evidence-based care. Most CC research is from the US, focusing on depression. As research results may not transfer to other settings, we developed and tested a Danish CC-model (the Collabri-model) for depression, panic disorder, generalized anxiety disorder, and social anxiety disorder in general practice. METHODS Four cluster-randomized superiority trials evaluated the effects of CC. The overall aim was to explore if CC significantly improved depression and anxiety symptoms compared to treatment-as-usual at 6-months' follow-up. The Collabri-model was founded on a multi-professional collaboration between a team of mental-health specialists (psychiatrists and care managers) and GPs. In collaboration with GPs, care managers provided treatment according to a structured plan, including regular reassessments and follow-up. Treatment modalities (cognitive behavioral therapy, psychoeducation, and medication) were offered based on stepped care algorithms. Face-to-face meetings between GPs and care managers took place regularly, and a psychiatrist provided supervision. The control group received treatment-as-usual. Primary outcomes were symptoms of depression (BDI-II) and anxiety (BAI) at 6-months' follow-up. The incremental cost-effectiveness ratio (ICER) was estimated based on 6-months' follow-up. RESULTS Despite various attempts to improve inclusion rates, the necessary number of participants was not recruited. Seven hundred thirty-one participants were included: 325 in the depression trial and 406 in the anxiety trials. The Collabri-model was implemented, demonstrating good fidelity to core model elements. In favor of CC, we found a statistically significant difference between depression scores at 6-months' follow-up in the depression trial. The difference was not significant at 15-months' follow-up. The anxiety trials were pooled for data analysis due to inadequate sample sizes. At 6- and 15-months' follow-up, there was a difference in anxiety symptoms favoring CC. These differences were not statistically significant. The ICER was 58,280 Euro per QALY. CONCLUSIONS At 6 months, a significant difference between groups was found in the depression trial, but not in the pooled anxiety trial. However, these results should be cautiously interpreted as there is a risk of selection bias and lacking statistical power. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02678624 and NCT02678845 . Retrospectively registered on 7 February 2016.
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Affiliation(s)
- Nadja Kehler Curth
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark.
| | - Ursula Ødum Brinck-Claussen
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
- Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
| | - Annette Sofie Davidsen
- The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Øster Farimagsgade 5, Postbox 2099, 1014, Copenhagen K, Denmark
| | - John Hagel Mikkelsen
- Mental Health Center Frederiksberg, Mental Health Services, Nordre Fasanvej 57-59, 2000, Frederiksberg, Denmark
| | - Marianne Engelbrecht Lau
- Stolpegård Psychotherapy Center, Mental Health Services, Stolpegårdsvej 20, 2820, Gentofte, Denmark
| | | | - Claudio Csillag
- Mental Health Center North Zealand, Mental Health Services, Dyrehavevej 48, 3400, Hillerød, Denmark
| | - Kaj Sparle Christensen
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Research Unit for General Practice, Institute of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Marie Jakobsen
- VIVE - The Danish Center for Social Science Research, Herluf Trolles Gade 11, 1052, Copenhagen K, Denmark
| | - Anders Bo Bojesen
- VIVE - The Danish Center for Social Science Research, Herluf Trolles Gade 11, 1052, Copenhagen K, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
- Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Falgaard Eplov
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
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Curth NK, Brinck-Claussen U, Jørgensen KB, Rosendal S, Hjorthøj C, Nordentoft M, Eplov LF. Collaborative care vs consultation liaison for depression and anxiety disorders in general practice: study protocol for two randomized controlled trials (the Danish Collabri Flex trials). Trials 2019; 20:607. [PMID: 31653228 PMCID: PMC6814969 DOI: 10.1186/s13063-019-3657-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 08/13/2019] [Indexed: 01/18/2023] Open
Abstract
Background Models of collaborative care and consultation liaison propose organizational changes to improve the quality of care for people with common mental disorders, such as anxiety and depression. Some literature suggests only short-term positive effects of consultation liaison on patient-related outcomes, whereas collaborative care demonstrates both short-term and long-term positive effects. To our knowledge, only one randomized trial has compared the effects of these models. Collaborative care was superior to consultation liaison in reducing symptoms of depression for up to 3 months, but the authors found no difference at 9-months' follow-up. The Collabri Flex Trial for Depression and the Collabri Flex Trial for Anxiety aim to compare the effects of collaborative care with those of a form of consultation liaison that contains potential contaminating elements from collaborative care. The trials build on knowledge from the previous cluster-randomized Collabri trials. Methods Two randomized, investigator-initiated, parallel-group, superiority trials have been established: one investigating the effects of collaborative care vs consultation liaison for depression and one investigating the effects of collaborative care vs consultation liaison for generalized anxiety, panic disorder and social anxiety disorder at 6-months' follow-up. Participants are recruited from general practices in the Capital Region of Denmark: 240 in the depression trial and 284 in the anxiety trial. The primary outcome is self-reported depression symptoms (Beck Depression Inventory (BDI-II)) in the depression trial and self-reported anxiety symptoms (Beck Anxiety Inventory (BAI)) in the anxiety trial. In both trials, the self-reported secondary outcomes are general psychological problems and symptoms (Symptom Checklist 90-Revised), functional impairment (Sheehan Disability Scale) and general well-being (World Health Organization-Five Well-Being Index). In the depression trial, BAI is an additional secondary outcome, and BDI-II is an additional secondary outcome in the anxiety trial. Explorative outcomes will also be collected. Discussion The results will supplement those of the cluster-randomized Collabri trials and provide pivotal information about the effects of collaborative care in Denmark. Trial registration ClinicalTrials.gov, NCT03113175 and NCT03113201. Registered on 13 April 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3657-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadja Kehler Curth
- Research Unit, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 15A, 4th floor, DK-2900, Hellerup, Denmark.
| | - Ursula Brinck-Claussen
- Research Unit, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 15A, 4th floor, DK-2900, Hellerup, Denmark
| | - Kirstine Bro Jørgensen
- Research Unit, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 15A, 4th floor, DK-2900, Hellerup, Denmark
| | - Susanne Rosendal
- Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Nordre Fasanvej 59, Vej 5, 12, 2nd floor, DK-2000, Frederiksberg, Denmark
| | - Carsten Hjorthøj
- Research Unit, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 15A, 4th floor, DK-2900, Hellerup, Denmark
| | - Merete Nordentoft
- Research Unit, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 15A, 4th floor, DK-2900, Hellerup, Denmark
| | - Lene Falgaard Eplov
- Research Unit, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 15A, 4th floor, DK-2900, Hellerup, Denmark
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Girard A, Ellefsen É, Roberge P, Carrier JD, Hudon C. Challenges of adopting the role of care manager when implementing the collaborative care model for people with common mental illnesses: A scoping review. Int J Ment Health Nurs 2019; 28:369-389. [PMID: 30815993 DOI: 10.1111/inm.12584] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2019] [Indexed: 01/05/2023]
Abstract
This review aimed to identify the main factors influencing the adoption of the role of care manager (CM) by nurses when implementing the collaborative care model (CCM) for common mental illnesses in primary care settings. A total of 19 studies met the inclusion criteria, reporting on 14 distinct interventions implemented between 2000 and 2017 in five countries. Two categories of factors were identified and described as follows: (i) strategies for the CCM implementation (e.g. initial care management training and supervision by a mental health specialist) and (ii) context-specific factors (e.g. organizational factors, collaboration with team members, nurses' care management competency). Identified implementation strategies were mainly aimed towards improving the nurse's care management competency, but their efficacy in developing the set of competencies needed to fulfil a CM role was not well demonstrated. There is a need to better understand the relationship between the nurses' competencies, the care management activities, the strategies used to implement the CCM and the context-specific factors. Strategies to optimize the adoption of the CM role should not be solely oriented towards the individual's competency in care management, but also consider other context-specific factors. The CM also needs a favourable context in order to perform his or her activities with competency.
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Affiliation(s)
- Ariane Girard
- School of Nursing, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Édith Ellefsen
- School of Nursing, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Pasquale Roberge
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada.,CHUS Research Centre, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jean-Daniel Carrier
- Department of Psychiatry, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada.,CHUS Research Centre, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada
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Overbeck G, Brostrøm Kousgaard M, Davidsen AS. Enactments and experiences of 'enhanced interprofessional communication' in collaborative care - a qualitative study. J Interprof Care 2018; 33:519-527. [PMID: 30358462 DOI: 10.1080/13561820.2018.1538109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
One of the key components in collaborative care (CC) for anxiety and depression between general practitioners (GPs) and psychiatry is 'enhanced interprofessional communication'. However, the literature contains few detailed descriptions of the interprofessional roles and specific collaborative behaviours that are required to enhance communication. Using semi-structured interviews and observations, this study explores how interprofessional communication was enacted in a CC intervention in Denmark. Analysis was by Interpretative Phenomenological Analysis and interaction analysis. In the intervention the components of the enhanced communication were a) weekly meetings between care managers (CMs) and GPs and b) group supervision of GPs by a psychiatrist. This study showed that the meetings between CMs and GPs were enacted very differently across clinics, with communication ranging from monological 'giving report'-style to more dialogical 'peer-discussion'-style with development of new shared knowledge. The type of communication depended on the GP's professional style. The supervision element was not perceived as being meaningful and GPs reacted by non-attendance and non-response. Engagement of the GPs in a shared process requires a more dialogical model. However, the choice depends on whether a referral or a collaborative model is aimed at. A dialogical model would demand the teaching and guidance of the professionals.
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Affiliation(s)
- Gritt Overbeck
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen , Denmark
| | - Marius Brostrøm Kousgaard
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen , Denmark
| | - Annette Sofie Davidsen
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen , Denmark
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Møller MCR, Mygind A, Bro F. Who needs collaborative care treatment? A qualitative study exploring attitudes towards and experiences with mental healthcare among general practitioners and care managers. BMC FAMILY PRACTICE 2018; 19:78. [PMID: 29848295 PMCID: PMC5977752 DOI: 10.1186/s12875-018-0764-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 05/18/2018] [Indexed: 01/13/2023]
Abstract
Background Collaborative care treatment is widely recognized as an effective approach to improve the quality of mental healthcare through enhanced and structured collaboration between general practice and specialized psychiatry. However, studies indicate that the complexity of collaborative care treatment interventions challenge the implementation in real-life general practice settings. Four Danish Collaborative Care Models were launched in 2014 for patients with mild/moderate anxiety and depression. These involved collaboration between general practitioners, care managers and consultant psychiatrists. Taking a multi-practice bottom-up approach, this paper aims to explore the perceived barriers and enablers related to collaborative care for patients with mental health problems and to investigate the actual experiences with a Danish collaborative care model in a single-case study in order to identify enablers and barriers for successful implementation. Methods Combining interviews and observations of usual treatment practices, we conducted a multi-practice study among general practitioners who were not involved in the Danish collaborative care models to explore their perspectives on existing mental health treatment and to investigate (from a bottom-up approach) their perceptions of and need for collaborative care in mental health treatment. Additionally, by combining observations and qualitative interviews, we followed the implementation of a Danish collaborative care model in a single-case study to convey identified barriers and enablers of the collaborative care model. Results Experienced and perceived enablers of the Danish collaborative care model mainly consisted of a need for new treatment options to deal with mild/moderate anxiety and depression. The model was considered to meet the need for a free fast track to high-quality treatment. Experienced barriers included: poor adaptation of the model to the working conditions and needs in daily general practice, time consumption, unsustainable logistical set-up and unclear care manager role. General practitioners in the multi-practice study considered access to treatment and not collaboration with specialised psychiatry to be essential for this group of patients. Conclusions The study calls for increased attention to implementation processes and better adaptation of collaborative care models to the clinical reality of general practice. Future interventions should address the treatment needs of specific patient populations and should involve relevant stakeholders in the design and implementation processes. Electronic supplementary material The online version of this article (10.1186/s12875-018-0764-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marlene Christina Rosengaard Møller
- Research Unit for General Practice & Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Anna Mygind
- Research Unit for General Practice & Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Flemming Bro
- Research Unit for General Practice & Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
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Overbeck G, Kousgaard MB, Davidsen AS. The work and challenges of care managers in the implementation of collaborative care: A qualitative study. J Psychiatr Ment Health Nurs 2018; 25:167-175. [PMID: 29283474 DOI: 10.1111/jpm.12449] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2017] [Indexed: 11/29/2022]
Abstract
UNLABELLED WHAT IS KNOWN ON THE SUBJECT?: In collaborative care models between psychiatry and general practice, mental health nurses are used as care managers who carry out the treatment of patients with anxiety or depression in general practice and establish a collaborating relationship with the general practitioner. Although the care manager is the key person in the collaborative care model, there is little knowledge about this role and the challenges involved in it. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study shows that before the CMs could start treating patients in a routine collaborative relationship with GPs, they needed to carry out an extensive amount of implementation work. This included solving practical problems of location and logistics, engaging GPs in the intervention, and tailoring collaboration to meet the GP's particular preferences. Implementing the role requires high commitment and an enterprising approach on the part of the care managers. The very experienced mental health nurses of this study had these skills. However, the same expertise cannot be presumed in a disseminated model. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When introducing new collaborative care interventions, the care manager role should be well defined and be well prepared, especially as regards the arrival of the care manager in general practice, and supported during implementation by a coordinated leadership established in collaboration between hospital psychiatry and representatives from general practice. ABSTRACT Introduction In collaborative care models for anxiety and depression, the care manager (CM), often a mental health nurse, has a key role. However, the work and challenges related to this role remain poorly investigated. Aim To explore CMs' experiences of their work and the challenges they face when implementing their role in a collaborative care intervention in the Capital Region of Denmark. Methods Interviews with eight CMs, a group interview with five CMs and a recording of one supervision session were analysed by thematic analysis. Results The CM carried out considerable implementation work. This included finding suitable locations; initiating and sustaining communication with the GPs and maintaining their engagement in the model; adapting to the patient population in general practice; dealing with personal security issues, and developing supportive peer relations and meaningful supervision. Discussion We compare our findings to previous studies of collaborative care and advanced nursing roles in general practice. The importance of organizational leadership to support the CM's bridge-building role is emphasized. Implications for practice The planners of new collaborative care interventions should not only focus on the CM's clinical tasks but also on ensuring the sufficient organizational conditions for carrying out the role.
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Affiliation(s)
- G Overbeck
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - M B Kousgaard
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - A S Davidsen
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
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