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.