Aragonès et al. BMC Health Services Research (2022) 22:446 https://doi.org/10.1186/s12913-022-07872-z RESEARCH Open Access Barriers, facilitators, and proposals for improvement in the implementation of a collaborative care program for depression: a qualitative study of primary care physicians and nurses Enric Aragonès1,2*, Germán López‑Cortacans1,2, Narcís Cardoner3,4,5, Catarina Tomé‑Pires6, Daniel Porta‑Casteràs3,4, Diego Palao3,4,5 and the INDI·I Research Team Abstract Background: Primary care plays a central role in the treatment of depression. Nonetheless, shortcomings in its management and suboptimal outcomes have been identified. Collaborative care models improve processes for the management of depressive disorders and associated outcomes. We developed a strategy to implement the INDI collaborative care program for the management of depression in primary health care centers across Catalonia. The aim of this qualitative study was to evaluate a trial implementation of the program to identify barriers, facilitators, and proposals for improvement. Methods: One year after the implementation of the INDI program in 18 public primary health care centers we performed a qualitative study in which the opinions and experiences of 23 primary care doctors and nurses from the participating centers were explored in focus groups. We performed thematic content analysis of the focus group transcripts. Results: The results were organized into three categories: facilitators, barriers, and proposals for improvement as per‑ ceived by the health care professionals involved. The most important facilitator identified was the perception that the INDI collaborative care program could be a useful tool for reorganizing processes and improving the management of depression in primary care, currently viewed as deficient. The main barriers identified were of an organizational nature: heavy workloads, lack of time, high staff turnover and shortages, and competing demands. Additional obstacles were inertia and resistance to change among health care professionals. Proposals for improvement included institutional buy-in to guarantee enduring support and the organizational changes needed for successful implementation. Conclusions: The INDI program is perceived as a useful, viable program for improving the management of depres‑ sion in primary care. Uptake by primary care centers and health care professionals, however, was poor. The iden‑ tification and analysis of barriers and facilitators will help refine the strategy to achieve successful, widespread implementation. *Correspondence: earagones.tgn.ics@gencat.cat 1 Primary Care Area Camp de Tarragona, Catalan Health Institute, Carrer dels Horts, 6, 43120 Constantí, Tarragona, Spain Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Aragonès et al. BMC Health Services Research (2022) 22:446 Page 2 of 11 Trial registration: ClinicalTrials.gov identifier: NCT03​285659; Registered 18th September, 2017. Keywords: Depressive disorder, Primary health care, Health plan implementation, Disease management, Qualitative research, Focus groups Introduction successful implementation in daily practice and propos- Depression is a critical public health problem that has a als for improvement. significant impact on patients, the people around them, and society as a whole [1]. According to the ESEMeD- Methods Spain survey, 10.6% of non-institutionalized Spanish Design overview adults have had major depressive symptoms at some One year after launching our strategy to promote the point in their life and 4% have had episodes in the past implementation of the INDI collaborative care program 12 months [2]. The cost of depression in Spain was esti- for the management of depression in primary care, we mated at €10,763 million in 2010, with indirect costs undertook an exploratory qualitative study using focus related to work productivity losses and disability account- groups to explore the perceptions of the primary care ing for 45% of the total [3]. doctors and nurses from the participating centers. The most common mental health disorders can be The study protocol was approved by the Clinical managed effectively and efficiently in primary care [4]. Research Ethics Committee of the Jordi Gol Primary This includes depression, but shortcomings in diagno- Care Research Institute (IDIAP) in Barcelona (P17/077; sis, treatment, and follow-up often lead to unsatisfactory 15/03/2017). Informed consent was obtained from all clinical outcomes [5, 6]. participants. The study was registered at ClinicalTrials. Collaborative care models, which are based on the gov (NCT03285659; 18/09/2017). It was conducted and chronic care model [7] can improve the management of reported in accordance with the consolidated criteria for chronic illnesses, such as depression. These models are reporting qualitative studies (COREQ) [16]. shared care plans where health professionals from differ- ent levels of care coordinate the management of patients Setting within a common structure that includes systematic The program was implemented in primary care centers planning of care provision and follow-up [8]. Collabora- in two health care districts: Tarragona-Valls, located in tive care models improve processes for the management southern Catalonia, and Vallès Occidental, located in the of depression and result in better clinical outcomes [9]. metropolitan region of Barcelona. Twelve centers, with The evidence to date indicates that their wider imple- 146 doctors, 136 nurses, and an assigned population of mentation should be recommended, particularly in pri- 209,591 people, participated in the first district, while six mary care settings [10, 11]. centers, with 88 doctors, 81 nurses, and an assigned pop- Difficulties, however, are encountered when complex ulation of 144,884 people, participated in the second. As models such as these are integrated into clinical practice the goal of the study was to test the program in real-life [12, 13]. Our team designed and implemented a strategy conditions, no exclusion criteria were applied to either for the widescale implementation of a multicomponent centers or health care professionals. collaborative care program (INDI) designed to improve the management of depression in primary care cent- Participants ers within the Catalan public health system [14]. Results Primary care doctors and nurses from the centers in from a clinical trial assessing the efficacy of the program both study districts were recruited to the focus groups. indicated that its implementation would be beneficial Recruitment was purposive. We decided to separate doc- [15]. tors and nurses into different groups to encourage frank The aim of this study was to evaluate a trial implemen- and open discussions and prevent any one group from tation of the INDI collaborative care program in real-life dominating the discussion. Doctors, for example, might clinical practice using a qualitative design in which we be expected to have more elaborated opinions on how explored the opinions and experiences of the primary depression should be managed. The obvious disadvantage care doctors and nurses involved. We employed a com- of separating the groups was that it did not allow for the prehensive approach in which in addition to evaluating sharing and exploration of different perspectives. Partici- the implementation, we studied the influence of program pants had to have had direct experience in the manage- characteristics and contextual factors on the process. ment of patients with depression and be familiar with the We focused on perceived barriers to and facilitators of key principles and characteristics of the INDI program Aragonès et al. BMC Health Services Research (2022) 22:446 Page 3 of 11 [14, 15], regardless of the level of uptake at their center. Data collection They did not receive any compensation for their partici- Four focus groups were held: one each with primary care pation. Their characteristics are summarized in Table 1. doctors (TD) and nurses (TN) in the Tarragona-Valls dis- trict and one each with primary care doctors (SD) and Program implementation nurses (SN) in the Vallès Occidental district. INDI is a multicomponent collaborative care program The script for the focus groups was prepared in accord- designed to meet the characteristics and needs of the ance with the study objectives. Rather than using pre- Catalan public primary care health system [15]. Its goal defined codes or evaluation areas, we prepared a short, is to improve the management of depression and clinical simple script that would allow us to explore emerging outcomes. Its cost-effectiveness was evaluated in a rand- categories and ideas based on the participants’ percep- omized controlled trial, which demonstrated a favorable tions and experiences (Table 3). Each group had a mod- incremental cost-effectiveness ratio and concluded that erator (GLC in Tarragona and DPC in Sabadell) and an its implementation could benefit both patients and the observer (CTP in Tarragona and NC in Sabadell) who health care system [15, 17]. took notes during the session, paying special attention to The PARIHS (Promoting Action on Research Imple- non-verbal language. Both the moderators and observ- mentation in Health Services) framework was used to ers are trained certified qualitative researchers [19], were design and deploy the strategy for transferring the inter- members of the team responsible for promoting the INDI vention to clinical practice [18]. A more detailed descrip- intervention, and had participated in meetings and train- tion of this strategy has been published elsewhere [14]. ing sessions attended by the focus group participants. Its main components and those of the INDI program are Their credentials and affiliations are listed in the author- summarized in Table 2. ship section of the article. Table 1 Sociodemographic and professional characteristics of focus groups participants Code Focus ­groupa Profession Gender Age (years) Years working in primary care TD1 TD Family doctor Female 49 14 TD2 TD Family doctor Male 52 24 TD3 TD Family doctor Female 41 12 TD4 TD Family doctor Female 58 31 TD5 TD Family doctor Female 45 16 TD6 TD Family ­doctorb Female 43 15 TN1 TN Primary care nurse Female 60 20 TN2 TN Primary care nurse Female 47 15 TN3 TN Primary care nurse Female 57 28 TN4 TN Primary care nurse Male 58 25 TN5 TN Primary care nurse Female 50 23 TN6 TN Primary care nurse Female 37 15 SD1 SD Family ­doctorb Female 42 14 SD2 SD Family doctor Male 50 22 SD3 SD Family doctor Female 56 30 SD4 SD Family doctor Female 55 29 SD5 SD Family doctor Male 38 11 SN1 SN Primary care nurse Male 48 25 SN2 SN Primary care nurse Female 54 29 SN3 SN Primary care nurse Female 43 20 SN4 SN Primary care nurse Female 44 18 SN5 SN Primary care nurse Female 58 28 SN6 SN Primary care nurse Female 48 25 a Focus groups performed: TD (family doctor in Tarragona); TN (primary care nurse in Tarragona); SD (family doctor in Sabadell); SN (primary care nurse in Sabadell) b professional with a special interest in mental health (‘more than average compared to my colleagues’) Aragonès et al. BMC Health Services Research (2022) 22:446 Page 4 of 11 Table 2 Main components of INDI program for the management of depression in primary care and the implementation strategy based on the PARIHS (Promoting Action on Research Implementation in Health Services) framework INDI program Redefinition of practitioner roles and care pathways within the primary care team Optimized management of depression. Interactive computerized clinical guideline to support patient monitoring and decision-making Introduction of the figure of care manager assigned to primary care nurses Patient psychoeducation program Improved liaison between primary care and psychiatry services. Shared care Implementation strategy Compilation and analysis of implicit evidence (knowledge and reflections of health care professionals and patients targeted by the program) and explicit evidence (clinical trials, economic evaluations, meta-analyses) Analysis of institutional setting and characteristics (e.g., organizational aspects, innovation culture, quality, continuous professional development) that could negatively or positively affect the implementation of the program Internal facilitators   − Regional leaders of INDI program linked to clinical management in both health care districts as a driver for local implementation   − Leading health care professionals to champion the program at each primary care center External facilitators provided by research team: online training for health care professionals, support and guidance, evaluation, feedback, local adaptation of intervention, accreditation of centers and practitioners, interinstitutional coordination. Table 3 Summary of focus group script −Experience with and opinion of the implementation of the INDI program, in whole or in part, in daily practice and at the primary health care center − Factors that influence the implementation of changes promoted by the INDI program (difficulties and barriers, and facilitators) − Identification and prioritization of actions or factors that could improve the implementation of the INDI program and make it more effective and useful The focus groups were held in meeting rooms of the triangulation of results [21]. The data were summarized, territorial delegations of the Catalan Institute of Health grouped into conceptual categories, and analyzed using in Tarragona and Sabadell and lasted approximately standard qualitative research techniques in collaboration 90 min each. The participants were familiar with the gen- with the study researchers (GLC, CTP, EA). No software eral objectives of the study and the relationship between was used to process the data. Participants were not asked the group moderators and the research team. All sessions for their opinions on the findings. were audio-recorded and transcribed in full. Field notes on direct observations and interactions Results between researchers and health care professionals at the Participation participating centers were taken throughout the imple- Eleven doctors with a mean (SD) age of 48.1 (6.7) years mentation process to complement other data. These and 12 nurses with a mean age of 50.3 (7.1) years par- notes were useful for contextualizing and better under- ticipated in the focus groups in the two districts. Their standing data obtained in the focus groups. demographic and professional characteristics are sum- marized in Table 1. Analysis The focus group transcripts and field notes were analyzed Results of analysis by themes [20]. Content analysis was used to highlight The results of the analysis were organized into three meanings within the text to describe and/or interpret categories according to the study objectives: (1) diffi- the themes that emerged. The steps in the above analy- culties and barriers to the effective implementation of ses were (a) careful reading of transcripts and field notes, the INDI program, (2) facilitators that could drive its (b) identification of relevant topics and texts, (c) break- implementation, and (3) suggestions from the health ing down of text into units of meaning, (d) coding of texts care professionals involved on how to improve the using a mix of predefined and emerging codes, (e) crea- implementation and effectiveness of the program for tion of categories that grouped together analogous codes the management of depression in clinical practice. In according to pre-established analytical criteria, (f ) anal- Table 4, within these categories we have classified the ysis of points of agreement and disagreement, and (h) results according to whether they were contextual (e.g., Aragonès et al. BMC Health Services Research (2022) 22:446 Page 5 of 11 Table 4 Summary of focus group thematic analysis results Obstacles Organization Lack of time Heavy workloads Staff shortages High staff turnover Changing, unstable leadership Diversity of teams Multiplicity of programs and initiatives (competing demands) Perceived lack of institutional buy-in Health care professionals and patients Apprehension, insecurity, lack of training/qualification among nurses Resistance among nurses to adopt new role Resistance among patients (to be managed by a nurse) Distrust of nurses’ work among doctors Difficulty coordinating shared work between doctors and nurses Routines, resistance to change among health care professionals Implementation strategy Top-down implementation, generating resistance among some professionals Lack of clarity in the definition of the care manager role Limitations in training program Difficulties coordinating shared care among primary care teams and psychiatry services. Compartmentalized work, not shared INDI program Complexity of the program Limitations in reliability of scales Facilitators General aspects Prevalence and importance of depression in primary care Current shortcomings in management of depression and need for improvement Recognition that depression should be managed by primary care Implementation strategy Useful, well-received training program INDI program Recognition, reinforcement, structuring, and systematization of the role of nurses Systematic use of guidelines and scales to facilitate structured management Greater access to and support from mental health specialists Proposals Healthcare institution Clear buy-in from institution Actions and measures to facilitate organizational changes required Inclusion of program in target payment system Involvement of health care professionals implementation decisions and design Stable doctor-nurse teams Implementation strategy Continued professional development for health care professionals Reinforcement of practical aspects of training Combination of online and face-to-face training sessions “Local” expert health care professionals to support teams Integration of depression management into community care Closer liaisons between primary care and mental health services INDI program More clearly defined roles for nurses (care managers) Development of a clear concept of shared care between primary care and psychiatry services healthcare organization, professionals, or patients), The INDI program was largely perceived as an oppor- whether they concerned the strategy and procedures tunity to restructure and improve the management carried out for implementation, or whether they could of depression, which was recognized as a common be attributed to the INDI program itself. and important condition whose current management Aragonès et al. BMC Health Services Research (2022) 22:446 Page 6 of 11 presented shortcomings and difficulties. Most of the “... the fact that it came straight from above was seen health care professionals interviewed were unsatisfied in a negative light...” (TD6) with the implementation process and results of the pro- The nurses, who have a key role in the INDI program, gram. They felt that it had not been implemented sys- said that they were motivated by the project, but also tematically or on a widespread scale, although they did mentioned that their lack of knowledge, skills, and train- recognize that some of its components had been partly ing in this area made them feel uneasy and insecure. They introduced. also had the impression that the goal of the program was “I see it as an opportunity for improvement, other to increase the responsibilities of nurses with the spuri- things we can do as nurses, a means for reinforcing ous aim of reducing the doctors’ workload the role of nurses” (TD2) “I think that training is missing, because the appre- hension that nurses feel about dealing with mental “Minimum implementation. Some doctors and a few health issues is due to a lack of training” (SN2) nurses have done it, but not many” (SD2) Mention was also made of shortcomings in coordination between doctors and nurses. Both groups agreed that Barriers to implementation it was not usual for nurses to follow-up on depression The main barriers to the successful implementation of in their visits with patients. On the one hand, patients the INDI program were of an organizational nature and showed resistance, while on the other, doctors were were viewed by the doctors and nurses as being outside slow to change their work routines by incorporating the their area of responsibility: work overload, a lack of time program’s recommendations on shared care. Some doc- for activities other than meeting patient demands, and tors expressed feelings of distrust towards nurses. They staff shortages and turnover rates that make it difficult, if also mentioned that nurses had not become sufficiently not impossible, to work as a team. involved and that it was difficult to accept managing “... We’re run off our feet in primary care, [...] so when depression as part of their role. a new task comes in, whether it’s related to mental “... integration of the concept of team is missing when health or something else, we tend to say no, because it comes to managing this disease” (TD4) of the volume of work” (SD2) “Do you think that doctors have done what they “... it’s been a complicated time. There aren’t enough should? [...] no patients have been shared with doctors...” (TN3) nurses” (TN3) “... there has been a lot of turnover: first you work “I have also encountered some resistance from some with one person, then with another, there’s very little nurses, hey ... I mean, apart from the inertia that we stability” (SN1) [doctors] have of “I’ll look after everything ...” (TD4) Reference was also made to the fact that numerous pro- Other barriers identified were coordination difficulties jects, programs, and training activities were launched between primary care and psychiatry, a lack of efficient at the same time, each competing for the doctors and communication procedures, and poorly defined tasks nurses’ time, attention, and effort. This creates resistance and responsibilities at each level of care. A mental health to accepting new initiatives, which are viewed as more support program requiring psychiatrists and psycholo- work. The field notes included various references to the gists to be physically present at some of the primary care perception among the health care professionals that the centers was implemented at the same time as the INDI health organization had not prioritized the implementa- program. This greater access to specialist support facili- tion of the INDI program. tated the coordination and integration of tasks, but it also “... we have daily training sessions on the ARES [a made it easier to hand over responsibilities for mental new system for recording nursing activities], ses- health care provision to these specialists. sions on how to manage chronic illnesses, the patient safety course, I mean, we have meetings and courses Facilitators every day…” (SN1) Our findings show that primary care doctors and nurses The perception that the program had been imposed top- largely recognize the significant impact of emotional down, without consultation, may have generated feelings problems in routine primary care practice and their link of resistance. to general health. They also perceived deficiencies in the Aragonès et al. BMC Health Services Research (2022) 22:446 Page 7 of 11 management of mental health disorders. Because the are more of a “psychologist” than we are [doctors], INDI program focuses on perceived needs, these percep- they are the ones managing the patients ... they also tions should conceptually facilitate its implementation. have long visits in which they can go into things in more depth, in a more relaxed environment, than we “...mental health has always been neglected... And we can” (SD4) see this in primary care: 90% of what we deal with is related to emotional issues” (SN2) Systematic use of questionnaires, such as the suicide risk screening questionnaire and the Patient Health Ques- There was a call for the primary care system to take on an tionnaire (PHQ-9) to quantify depression severity and increasing role in managing patients with depression and monitor symptoms and response to treatment over time, other mental health disorders. was uncommon before recommended by the INDI pro- “... the health system is increasingly transferring gram. The health care professionals were of the opinion more and more mental health competencies to pri- that these questionnaires were now easy to administer in mary care [...]. We are in a process of change [...]. Yes, routine practice as they had been included in the elec- we are saturated, yes, we have heavy workloads, but tronic medical record system. They recognized their use- we want to take on this role” (SN2) fulness as a clinical monitoring tool. Some nurses were in favor of working more with men- “As for indicators, the PHQ-9 and changes to diag- tal health. They were motivated and willing and saw the nostic practices, yes, this has happened in the last project as an opportunity to take on a greater role by 2 years, quite a lot, a lot, has been done. Both the working together with primary care doctors and mental suicide risk questionnaire and the PHQ-9 have been health specialists. They were of the opinion that the INDI used quite a lot” (SN3) program provides useful tools and the means to build on The relationship with psychiatry and psychology teams work that is already being done, often in an unstructured was generally perceived as good and those interviewed way: follow-up and control, detection of episodes, treat- mentioned that they appreciated their accessibility and ment adherence, and the combined management of men- support. tal health illnesses and somatic comorbidities. “And the relationship with the psychologist/psychia- “These patients shouldn’t have to go to the doctor trist at the center is fantastic too. We didn’t have a often. They should be managed by nurses” (TN2) relationship and now we do, I have to give you that” (TD1) “... in some way, it built on everything that was being done […]. But I must say that mental health is dealt “... we do, doctors and nurses participate. If there are with in combination with other diseases in our prac- specific issues to deal with, even the social worker tice, because it’s not a separate thing, everything is comes” (SD1) mixed up and everything is treated at the same time.” (SN3) It was largely agreed that an interdisciplinary approach Proposals for improvement to mental health care provision was a good idea. Some Buy-in from the Catalan Health Institute and primary participants also mentioned that when the program had health care center management is critical to the effective been implemented, even partially, the doctor-nurse dyad implementation of the guidelines and tools contemplated had worked well. within the INDI program. Enduring institutional support “Some people are implementing the program [...], but must be guaranteed alongside organizational changes more because certain nurses are personally moti- needed to improve the functioning of primary care teams vated and work well with the doctors than because and their relationship with mental health services. of a widespread interest within the team” (SN2) “If management at each center was committed, said Some doctors considered that nurses were equipped to ’I’m going to do it, I’m going to implement this in my follow up on patients with depression; they said that they center’ and they look for a model to follow and with knew how to do this, were committed, knew the patients support from mental health services [...] we’re in” well, had their trust, and had longer visits with them than (TN1) the doctors. Clear institutional buy-in was considered a key fac- “... [nurses] can do this perfectly, and sometimes they tor to the success of any new program; this could be achieved by including the program, with specific, Aragonès et al. BMC Health Services Research (2022) 22:446 Page 8 of 11 measurable indicators, in the institute’s target pay- “... one way to do this would be to create a clini- ment system (DPO, Direcció per objectius). General cal pathway, as with any other chronic illness. You recommendations on the merits of a given project, by standardize it: diagnosis, questionnaire, initial contrast, lead to heterogeneous results, as their suc- diagnosis, risk of suicide, guidance, if it’s mild no cess depends on the willingness and resources of each drugs, if it’s moderate, or whatever, drugs, nurses, center and its staff. number of follow-up visits” (SD1) “Question: Do you think that if the INDI program, Community care was identified as an area where the in its current format, had been included in the DPO INDI program could be implemented and progressively [target payment] system... expanded. One advantage of this approach would be that community care nurses could apply their existing experi- Answer: Yes, definitely. Sadly yes, I think this is the ence and know-how to help prevent and manage depres- case. The results would be completely different” sion within the community. (TD5). “So many things are interlinked in the community. Although the focus group participants believed that We could do this as part of community care” (SD1) institutional and management prioritization and sup- port were essential, they were also of the opinion that the health care professionals dealing with patients should be Discussion involved in these decisions. Primary care doctors and nurses recognize that mental “... we’re all saturated and when things are imposed health disorders, and depression in particular, are wide- from above ... it’s like ’the ball’s in your court now’, spread in routine clinical practice and acknowledge that and there’s no ’look, they’re looking to do this… we there are shortcomings in their current management. should do that...’. Team work and empowerment” They also view the INDI program as a potentially useful (SN1) tool for achieving higher-quality care. Uptake of the pro- gram, however, has been poor, both across primary care Other proposals that emerged were changes to primary centers and among health care providers. The main bar- care organizational structures, programming of visits, riers identified were problems perceived to be beyond the and internal pathways that would facilitate collabora- responsibility and control of the health care profession- tion between doctors and nurses and give them time to als: heavy workloads, insufficient time, staffing problems, address the needs of patients with depression. One pro- and a lack of institutional leadership. These findings are posal for facilitating collaborative work mentioned in the supported in the literature [22–24]. focus groups and field notes was the creation of stable The doctors and nurses interviewed, however, also doctor-nurse teams (unitat bàsica assistencial, UBA) with acknowledged problems linked to their own inertia and the same patients under their care. resistance to change. Doctors on the one hand were “... that’s why you need to improve the programming reluctant to share responsibilities for managing patients of visits, prepare a series of things so that nurses can with depression with nurses, while nurses were reluc- monitor patients with depression” (TN2) tant to take on new responsibilities. Resistance to change among health care professionals has been identified as “... maybe longer special visits should be pro- the most common barrier to the success of collaborative grammed, otherwise, there’s no time for psychoedu- care models [25, 26]. cation...” (SN3) The care manager is a key figure in collaborative care models. In the INDI model, this role is assigned to pri- “... we have improved by returning to the UBA [basic mary care nurses, who, working closely with the patient’s care unit consisting of a doctor and a nurse who primary care doctor, take on responsibilities in monitor- share and are co-responsible for the same patients], ing clinical course and treatment adherence and provid- because before that we shared our patients with all ing emotional and self-management support [27]. The the nurses” (TD3) figure of care manager is a novel concept in our setting and one that may prove difficult to accept or understand, Clearly defined roles and responsibilities and proper as it involves profound changes to the way depression has structuring of tasks and actions would build nurses’ con- traditionally been managed. Doctors have to relinquish fidence and help them overcome current resistance and responsibilities they have held for a long time, while fears in relation to their new role in managing patients nurse care managers have to take on new ones. An addi- with depression. tional challenge is the need to ensure smooth, effective Aragonès et al. BMC Health Services Research (2022) 22:446 Page 9 of 11 coordination. An explicit definition of the exact role and had extensive work experience. In addition, our find- responsibilities of a care manager, and one that is fully ings cannot be directly transferred to settings or health understood and accepted by all parties involved, will organizations with different characteristics. Nonethe- provide care managers with the necessary confidence to less, our focus group findings for the two health districts exercise their new functions and doctors with clarity on were similar and were also consistent with the field notes, the benefits of shared responsibilities. A lack of clarity on adding strength to the validity of our results. Second, we this definition has been highlighted as a major obstacle in did not interview other relevant stakeholders involved in other studies [28, 29]. It also probably partly explains the the INDI program, such as health care managers, men- resistance encountered among the doctors and nurses in tioned several times in this study, and patients, the ben- our study. Well-defined care manager roles and duties eficiaries of the program. Further research should explore are key to the success of the program and, in view of the the perspectives of all parties involved to obtain a more favorable attitudes detected among both nurses and doc- complete picture. Third, the INDI program focuses on tors, would probably result in a more effective implemen- depression only, but patients with depressive symptoms tation of this role [30, 31]. seen in primary care often have concomitant psychiatric Complexity has also been identified as a barrier to disorders, chronic physical illnesses, or social problems. effective implementation [32]. The INDI program is a This should be taken into account in future implementa- complex, multicomponent model involving various levels tions of the INDI collaborative care model [30, 36]. of care that need to be linked via clear, coordinated path- ways and procedures. This complexity, however, was not Conclusions explicitly mentioned in the focus groups. We did, how- This study provides useful information, based on real ever, see evidence of it in the field notes taken through- clinical practice, for the implementation of a collabo- out the process. Complexity is also implicit in several rative care program for the improved management of aspects of the program analyzed, such as difficulties with depression in primary care in Catalonia. Our results pro- shared case management within primary care teams and vide quite detailed insights into barriers to and facilita- between primary care teams and other levels and the fact tors of the integration of a complex collaborative care that only some components of the program were adopted program into clinical practice from the perspective of (e.g., use of questionnaires for monitoring symptoms). health care practitioners. A key question that remains is Similar difficulties have been reported elsewhere [33]. why uptake was low in our case. Was it the complexity Our study also identified important facilitators that of the intervention, shortcomings in the implementation should be harnessed to drive successful implementa- strategies employed, or contextual factors? Based on the tion. The participants recognized the existence of short- focus group findings, we believe that contextual factors comings in the current management of depression and related to the healthcare organization and the doctors viewed the INDI program as a valuable tool that could and nurses themselves were especially decisive. Real-life overcome these shortcomings. Our results confirm previ- implementation of collaborative care programs, however, ous reports of largely favorable attitudes among primary is complex and likely to have been influenced by multiple, care practitioners towards managing depression in pri- and often overlapping, factors from the three domains mary care [34, 35] and increasing nurses’ responsibilities and by interactions between these factors. Consideration in this area. These attitudes must be harnessed to drive of all these variables is key to successful implementation. effective change through clear institutional buy-in and Institutional buy-in and clear, proactive leadership leadership and the implementation of structural changes, are key to laying the ground for the changes required to but with an active bottom-up approach involving front- ensure the successful implementation of the program. line professionals and local clinical leaders to champion Inertia and resistance among practitioners must also be the program. This shared leadership and vision is essen- overcome. We have identified factors that can drive effec- tial and must filter down from the highest levels to every- tive implementation, in particular, the general perception day practice [25, 26]. among front-line practitioners that the INDI program can help overcome shortcomings in the current manage- Limitations ment of depression in primary care. Our study has several limitations that should be taken into account when interpreting our findings. First, the Abbreviations perceptions and opinions of the small number of primary ARES: Program for harmonization of nursing care standards; COREQ: Consoli‑ care physicians and nurses may not be representative of dated criteria for reporting qualitative research; DPO: Target payment system (in Catalan: Direcció per Objectius); ESEMED: European Study of the Epidemiol‑ those who did not participate in this study. One exam- ogy of Mental Disorders; IDIAP: Primary Care Research Institute (in Catalan: ple of this is that all the participants in our focus groups Institut d’Investigació en Atenció Primària); INDI: Interventions for Depression Aragonès et al. BMC Health Services Research (2022) 22:446 Page 10 of 11 Improvement (acronym for the collaborative care model in this project); Competing interests INNÒBICS: Open Research at the Catalan Health Institute (in Catalan: Innovació The authors declare that they have no competing interests. Oberta a l’ICS); PARIHS: Promoting Action on Research Implementation in Health Services; PERIS: Strategic Plan for Research and Innovation in Health Author details 1 (in Catalan: Pla Estratègic de Recerca i Innovació en Salut); PHQ9: Patient Health Primary Care Area Camp de Tarragona, Catalan Health Institute, Carrer dels Questionnaire, 9 items. Horts, 6, 43120 Constantí, Tarragona, Spain. 2 Primary Care Research Institute IDIAP Jordi Gol, Barcelona, Spain. 3 Mental Health Department, University Hos‑ Acknowledgements pital Parc Taulí, Sabadell, Spain. 4 Department of Psychiatry and Legal Medicine, This study has been possible thanks to the generous participation of the Autonomous University of Barcelona, Barcelona, Spain. 5 Biomedical Research primary care nurses and doctors in the focus groups. We are also grateful to all Networking Center Consortium on Mental Health (CIBERSAM), Madrid, Spain. 6 the health care professionals and patients at the primary care centers where Psychology Research Center CIP, Autonomous University of Lisbon, Lisbon, the implementation of the INDI program was tested and to Núria Coma and Portugal. Anna Berenguera (expert qualitative researchers at IDIAP Jordi Gol) for their help with the qualitative analysis and article outline. Received: 12 November 2021 Accepted: 28 March 2022 Consortium name: The INDI·i Research Team. Consortium authors: Eva Bellerino,7 Myriam Cavero,8 Eva Aguilar,3 Marta Subirà,3 Antonia Caballero,1 Pilar Casaus,9 José Antonio Monreal,3 Víctor Pérez- Sola,10,11 Miquel Cirera,12 Maite L­ oren12 and Laura Palacios.1 7 Primary Care Service Vallès Occidental, Catalan Health Institute, Sabadell; 8 References Mental Health Centre Esquerra Eixample, Hospital Clínic, Barcelona; 9 Univer‑ 1. Soriano JB, Rojas-Rueda D, Alonso J, Antó JM, Cardona PJ, Fernández E, sity Psychiatric Hospital Pere Mata Institute, Reus; 10 Institute of Neuropsychia‑ et al. The burden of disease in Spain: Results from the Global Burden of try and Addictions, Hospital del Mar, IMIM, Barcelona; 11CIBERSAM, Madrid; 12 Disease 2016. Med Clin (Barc). 2018;151:171–90. https://​doi.​org/​10.​1016/j.​ Healthcare Corporation Parc Taulí, Primary Care Area, Sabadell. medcli.​2018.​05.​011. 2. 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What work • fast, convenient online submission has to be done to implement collaborative care for depression? Process evaluation of a trial utilizing the normalization process model. Implement • thorough peer review by experienced researchers in your field Sci. 2010;5:15. https://​doi.​org/​10.​1186/​1748-​5908-5-​15. • rapid publication on acceptance 31. Whitebird RR, Solberg LI, Jaeckels NA, Pietruszewski PB, Hadzic S, Unützer • support for research data, including large and complex data types J, et al. Effective implementation of collaborative care for depression: what is needed? Am J Manag Care. 2014;20(9):699–707. • gold Open Access which fosters wider collaboration and increased citations 32. Bird VJ, Le Boutillier C, Leamy M, Williams J, Bradstreet S, Slade M. • maximum visibility for your research: over 100M website views per year Evaluating the feasibility of complex interventions in mental health services: standardised measure and reporting guidelines. Br J Psychiatry. At BMC, research is always in progress. 2014;204:316–21. https://​doi.​org/​10.​1192/​bjp.​bp.​113.​128314. 33. Nutting PA, Gallagher KM, Riley K, White S, Dietrich AJ, Dickinson WP. Learn more biomedcentral.com/submissions Implementing a depression improvement intervention in five health