Challenges in conducting research on collaborative mental health care: a qualitative study

Nadiya Sunderji; Allyson Ion; Annie Zhu; Athina Perivolaris; David Rodie; Benoit H. Mulsant

doi:10.9778/cmajo.20180172

Article Figures & Tables

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Table 1:

Characteristics of study participants

Characteristic	No. (%) of participants^* n = 23
Geographic location of practice
Urban	14 (61)
Rural	9 (39)
Health discipline
Family physician	12 (52)
Nurse practitioner	5 (22)
Executive director	3 (13)
Social worker	2 (9)
Registered nurse	1 (4)
Type of practice
Family Health Team	13 (56)
Community health centre	6 (26)
Other group practice^†	3 (13)
Solo practice	1 (4)
Previous participation in research	18 (78)
Role in past research (n = 18)
Referring provider	8 (44)
Study participant	4 (22)
Collaborator	1 (6)
Investigator	1 (6)
> 1 role	4 (22)
No. of years in practice
Mean ± SD	14.0 ± 12.7
Median (range)	9 (2–51)

Note: SD = standard deviation.
↵* Except where noted otherwise.
↵† University student health centre.

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Table 2:

Study participants by referral stratum

Geographical setting	Practice referral rate^*	Individual primary care provider referral rate^†	No. of primary care providers eligible n = 175	No. of primary care providers interviewed n = 19	No. of site liaisons interviewed^‡ n = 4
Urban	High (n = 4)	High	27	6	1
		Low	20	1	0
		No referrals	20	1	0
	Low (n = 4)	High	3	1	2
		Low	15	2	0
		No referrals	40	1	1
Rural	High (n = 4)	High	11	0	0
		Low	4	1	0
		No referrals	7	0	0
	Low (n = 2)	High	4	3	0
		Low	9	0	0
		No referrals	15	3	0

↵* Practices with high referral rates made more than 0.15 referrals per month on average per family physician or nurse practitioner in the practice; practices with low referral rates made 0.15 or fewer.
↵† High = more than 0.2 referrals per month on average; low = 0.2 referrals or fewer per month on average.
↵‡ There was 1 site liaison per study site (n = 14) and 1 liaison for a study site that withdrew from PARTNERs early in the study; we contacted all of them.

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Table 3:

Perceived strengths and weaknesses of collaborative care in PARTNERs

Collaborative care element	Definition	How manifested in PARTNERs (for patients who received intervention)	Participant perspective
Support for patient self-management	Coaching, problem solving, or psychoeducation or skills-focused psychotherapy to increase ability to manage symptoms and effectively participate in care and decision-making	Lay provider (MHT) provided telephone monitoring and self-management support and, later, relapse prevention support; telephone calls were typically weekly × 3 mo, then monthly × 3 mo or potentially longer to a maximum of 1 yr MHT supervised weekly by study psychiatrist	Seen as a unique and valuable resource for patients (in a broader climate of limited access) Strongly expected to be of benefit to many patients Telephone communication thought to vary in appeal and feasibility for patients Trusted that MHTs were qualified; some wanted more familiarity with them Would have liked greater integration of MHT into their setting, more frequent and bidirectional communication to share their knowledge of the patient and his or her past treatments, or co-location to enable “warm handoffs”
Use of clinical information systems for timely data	Facilitated flow of patient- or population-level data to clinicians, e.g., via reports of patient results, case registries, reminder systems	Patient’s FP or NP received individual patient data monthly × 3 mo (while MHT followed patient weekly), then quarterly (while MHT followed patient monthly) for a maximum of 1 yr Reports included Patient Health Questionnaire-9 score and other questionnaire scores as appropriate, a brief summary of care with MHT and any recommendations from study psychiatrist	Theoretically useful, but some had difficulty recalling what they received, and blinded patient randomization also made their opinions difficult to interpret Could validate PCP impression, provide information not known to the PCP, or discuss referrals that were seen by the PCP as redundant or previously tried Telephone contact between MHT and PCP initiated by MHT was rare and greatly appreciated when it occurred; very rarely (if ever) initiated by PCP Rarely identified any changes to their practice as a result of receiving reports or knowing about MHT involvement (perhaps because of practice habits and small number of their patients involved with PARTNERs intervention)
Delivery system redesign	Team-based care (v. physician-only care) to provide education, self-management support, information flow and overall proactive rather than reactive care	Addition of MHT and study psychiatrist at a distance	Embraced the concept of team-based primary care for people with common mental disorders, e.g., depression, anxiety; typically identified other conditions (e.g., bipolar disorder, posttraumatic stress disorder) as appropriate for follow-up in specialty care Many did not view the MHT care manager as an integrated member of the care team or a resource to the primary care setting
Decision support for health care providers	On-site or distal psychiatrist consultation to PCPs or provision of simplified clinical practice guidelines supported by clinician champions	Based on discussion with MHT and an algorithm, study psychiatrist provided recommendations for optimizing treatment in reports	Appreciated study psychiatrist recommendations but did not necessarily act on them any sooner than the next scheduled patient appointment
Linkage to community resources	Referrals to external resources to support clinical and nonclinical needs (e.g., peer support, exercise, home care)	Not formally a component of PARTNERs intervention	Mixed perspectives on whether these may be best identified, introduced and referred to by the local primary care team versus the distal collaborative care team
Support for health care organizations	Leadership, training, staffing, informatics and other tangible resources to support adoption and implementation of collaborative care goals and practices	Not formally a component of PARTNERs intervention (although PARTNERs team did provide an optional initial on-site orientation to the study for local primary care teams)	Identified as a major gap Leadership support for participation in PARTNERs varied greatly and influenced adoption and implementation Lack of training and ongoing support resulted in difficulty (e.g., knowing how to introduce the study to patients, whether the study was ongoing and continuing to accept new referrals) Interprofessional staff involvement (i.e., beyond physicians) would be required to facilitate more proactive care Staff turnover was common and created discontinuity in knowledge of and engagement with the study Informatics capabilities (e.g., searches or flags in the electronic medical record to facilitate identification of eligible patients) could assist with proactive care; again, would require interprofessional staff involvement

Note: FP = family physician, MHT = mental health technician, NP = nurse practitioner, PARTNERs = Primary Care Assessment and Research of a Telephone Intervention for Neuropsychiatric Conditions with Education and Resources study, PCP = primary care provider.

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Table 4:

Primary care providers’ perspectives on patient and study characteristics that influenced referrals

Variable	Increased likelihood of referral	Decreased likelihood of referral
Patient characteristics
Mental health diagnosis congruent with telephone-based support	Anxiety disorders: “I think, for anxiety ... it was really helpful as well, actually, by phone call initially because a lot of my patients did have struggles getting to any appointment because they’re too anxious to leave the house, they’re too anxious to do just anything. … They’ll answer the call, and they actually like talking with somebody from the safety of their own home.” (1002, family physician)	Comorbid substance use and alcohol use: “I think addiction care over the phone might be kind of hard, personally. And I didn’t refer any of my clients in particular related to ... alcohol use … because I’ve never had a patient who was ... willing to cut down drinking or was interested in getting support for cutting down drinking who would be willing to do it by phone.” (15001, nurse practitioner)
Stage of mental illness	New onset of depression/anxiety: “I certainly have a lot of patients with depression and anxiety who I didn’t refer, [for referrals] it tends to be people who are walking in with a new symptom. … I think for people I’ve been following for a long time, it’s just not in my algorithm.” (1004, family physician)	Acute/crisis: “It was mostly if we felt that a client was a little bit more acute and not so much in a more stable environment for that phase in regards to their depression or anxiety. Then we would focus more on getting that client’s needs met in regards to the counselling that [he or she] needed or being seen by a psychiatrist. So not so much being followed and screened but more intervention. … Once we felt that, they were a little bit more stable. … And a lot of them did actually go through the PARTNERs study afterwards.” (15003, nurse practitioner)
Sociodemographic characteristics	Patient characteristics influencing motivation and perceived capacity to self-manage: “I have kind of more of the working, younger, healthier, a better mixed population … which probably also is why I had more referrals than others — because my patients are more motivated to be self-managed and seek access to a dietitian, access to a social worker, that kind of stuff. And I have an easier time getting my patients to do that than they do at the other sites [that have] … a sicker, older population.” (15002, nurse practitioner)	Language barriers: “Language barrier was one that we took into consideration as well. … We do have a really high francophone community. So that was one of the barriers that we encountered quite a bit. ... We have a big elderly population as well. ... They do deal with depression, especially during the wintertime as well. So it would have been a great resource for them because it doesn’t require them to come out of their home ... it reduces the risks of falls and all that. But I wasn’t able to utilize the PARTNERs study for them because they only speak or understand French.” (15003, nurse practitioner)
Primary care provider perceptions of patient preferences	Timely response to a patient need: “Typically what would happen is a patient would come in in crisis, in need. Although we do have a social worker, they needed something more. ... And so offering them this as an interim, knowing that they would still get to the psychiatrist, seemed to alleviate some of that anxiety about ‘Okay, when am I going to have that appointment and how come I can’t get in tomorrow?’ And so having that sort of stepping stone, sometimes it worked extremely well, and I know that some patients thought it was great.” (12001, manager/director)	Patient preferences for embedded/local service: “At our family health team, we have a social worker who does counselling. So when I bring these things up, I sort of put the option for counselling that we have on the table. And most of my other currently depressed people are a little more in that 40-, 50-year-old range, and they were quite happy to just do regular counselling. So it wasn’t that I intentionally didn’t refer, it was that they were happy with the resources at the site.” (5001, family physician) “I have some patients who just have had a bad experience with ‘the hospital,’ and they won’t have anything to do with it. So I’ve had that a couple of times.” (1004, family physician) Relationship with primary care provider: “I wouldn’t refer people who are really busy or involved in a lot … or I felt like we need to work on the therapeutic alliance a little bit more.” (1001, social worker)
Study characteristics
Eligibility criteria	Hope to link patient with support through study: “There were a couple of people I referred who had trauma who I still hoped ... would get in, and they were not eligible. So I still referred some people even though they met your exclusion criteria just in hopes that they might get some extra support.” (15001, nurse practitioner)	High prevalence of comorbid disorders in practice: “A huge portion of my practice [is] high rates of substance abuse, high rates of posttraumatic stress disorder and high rates of bipolar [disorder]. So to come across somebody with just depression or anxiety is pretty rare.” (15002, nurse practitioner)
Randomization	Randomization necessary to evaluate intervention: “I think it’s [randomization] part of the research beast. ... If you want a good study, you probably have to do some sort of randomization. And so I understand that from a research principle. So it doesn’t particularly affect me negatively.” (5001, family physician) Hope to link patient with support through study: “No, I never considered whether they would get the help or not. I just knew that this is something we could offer them. … And I hope that those people that needed the help got it … it [randomization] didn’t stop me from doing it.” (12001, manager/director)	Need for immediate support and chance of not receiving intervention owing to randomization: “I was kind of concerned if someone needed more of that regular support and ... symptom check-in and psychoeducation ... I wouldn’t be confident that [he or she] would necessarily get that from PARTNERs. So I’d prefer to actually either see [that patient] ... fairly regularly myself or refer to our social worker if needed. ... So I would say for patients who were maybe more severe for whom I felt ... that more frequent monitoring was necessary, I chose not to refer because that risk of randomization was there.” (1003, family physician) “Some people will be randomized and won’t be able to access it. So ... if they really, really need the support ... we might not refer ... because we want 100% for them to get the support. So that thing of being randomized out would be one [reason not to refer].” (1005, manager/director) “They call it enhanced usual care versus the intervention. So ... enhanced usual care ... you actually do get some sort of feedback [with the added study-specific symptom rating scales, which], at a time when you wouldn’t have seen the patient, can be somewhat useful. But from a patient perspective, I don’t think it’s particularly different from what [he or she] would have had anyway. So I guess ... that’s ... the harder point — that you might get [the intervention], but you might not.” (1004, family physician) “When you try to talk to your patients about it, knowing that there’s a chance that they could end up in the control group and have much … more spaced out or infrequent assessments, I would say is kind of a down side. Knowing that ... just statistically maybe half your patients may end up in that group. In which case, there’s less of that support there. And I think that’s just something we all had to kind of keep in mind.” (1003, family physician)
Expected benefits for patients	Intervention accessibility: “Access to counselling here is a problem. And so just hoping to increase services is helpful. Lots of patients here have difficulty with access in terms of driving, being able to actually go somewhere to see a counsellor. So the fact that ... it’s phone contact was helpful. Not every person is super comfortable talking to somebody in person. And so phone sometimes helps sort of initiate or get things moving.” (12002, nurse practitioner) Witnessing patient benefits: “Until we actually made our first referral, understood the ramifications for the patients and actually saw some feedback, it didn’t really connect with us.” (12001, manager/director)	–
Expected benefits for providers	Study as a resource augmenting usual care (v. study as “research”): “It’s a research study about these 2 different interventions. It’s not a psychiatrist necessarily taking over my patient, saying ‘Here, we’re going to see this patient and assess [her] fully, and then we’ll do all this diagnosis and may start medications, and then we’ll send [her] back to you, and then work together.’ … It’s actually more of me looking after the patient but with these additional options … an add-on to my usual care. It’s not replacing it. … I just want [the patient] to be randomized, and it doesn’t matter because I’m going to be doing the usual care anyways. This is an add-on that could help [the patient].” (11001, family physician) “I don’t have the time in my schedule to actually make ... just a monitoring phone call appointment every week. Maybe on a monthly basis or so, then, yeah, that’s more feasible. But the PARTNERs study actually allowed me to give a little bit … step back a bit, and I knew that [the patient was] being monitored. And if there was a real concern, then it would be brought to my attention. So it was opening up my schedule.” (15003, nurse practitioner)	Lack of knowledge about intervention: “I don’t think I knew enough about [PARTNERs] or was comfortable enough about it during that time.” (13001, nurse practitioner) “I’m assuming it’s a knowledge gap, a deficit in education as to exactly how either the mental health technicians or nurses can help the patient. Sometimes I think there’s a stigma attached to an intervention that has the [term] ‘research study’ attached to it.” (13002, manager/director) Redundancy of service: “It was introduced as something that could be helpful. But I guess maybe it just didn’t take off ... [owing] to all the factors — of some of the social workers seeing it as maybe threatening their service ... patients seeing it as a duplication.” (18001, social worker) “Maybe I’m referring to our local psychiatric referral resource. … So you may not see it [referrals to PARTNERs] because … it’s hard to work with ‘the hospital’ when I have a local resource.” (11001, family physician)