Table 4:

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

VariableIncreased likelihood of referralDecreased likelihood of referral
Patient characteristics
Mental health diagnosis congruent with telephone-based supportAnxiety 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 illnessNew 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 characteristicsPatient 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 preferencesTimely 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 criteriaHope 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)
RandomizationRandomization 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 patientsIntervention 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 providersStudy 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)
  • Note: PARTNERs = Primary Care Assessment and Research of a Telephone Intervention for Neuropsychiatric Conditions with Education and Resources study.