Table 4 Summary description of the Collaborative Care intervention, using the Template for Intervention Description and Replication

Target-D Collaborative Care

WHY:

To address the need for an intervention to support people living with multimorbidity, in particular mental-physical multimorbidity. The key proposed mechanisms of the intervention, underpinned by Theory of Planned Behavior and motivational interviewing are to engage patients, focus intentionally on what is important to them, and empower them to make changes through a structured process of goal-setting, review, and individualised referral to support services and resources as appropriate.

WHO:

Patients in primary care waiting rooms complete an initial assessment and their scores indicate the likelihood of severe depression at 3 months. GPs are actively involved in the collaborative care process which is embedded in GP practices. Target-D nurses were all registered nurses.

WHAT:

Initial assessment: The initial assessment tool is an evidence-based algorithm to determine which patients are likely to experience severe depression in 3 months’ time.^aThe assessment also requires participants to select priority areas that are important to them from evidence-based areas for behaviour change to support improved mood and wellbeing, including: mood, anxiety, concentration, self-image, thoughts of death, concentration, health, appetite, interest, sleep, and energy.

Initial collaborative care consultation: Target-D nurses use MI to engage participants and to collaboratively set goals and develop a written action plan focused on participant’s priority areas.

Monitoring and review: Subsequent sessions continue the focus on participant priority areas, and aim to empower participants through collaborative review, providing referral or resources, and reinforcement for changes. Participants choose between face-to-face and telephone sessions.

Follow up: After each session participants receive a personalised and reinforcing email and a copy of the plan. Plans are shared with the GP and health care team. Templates and plans are included in the Target-D handbook to assist Target-D nurses to write in a way that emphasises patient perspectives and supports self-efficacy.

FREQUENCY AND DURATION:

The Target-D Collaborative Care intervention provides up to 8 sessions per patient. The initial session is designed to be a longer session, proposed to last approximately 60 min, with follow up sessions planned as shorter sessions of approximately 15–30 min duration. The first four sessions are conducted weekly, and the final four sessions are conducted fortnightly. The total duration of the intervention is approximately 3 months.

TAILORING:

The intervention is driven by the priority areas identified by participants. The intervention is flexible to participant preference for face-to face or telephone sessions. Referrals to other service providers or resources are tailored to the participant’s goals and preferences.