Chronic Disease Management - Implementation and coordination of health care systems for depressed elderly people

The primary objective of this four-year project was to examine whether the implementation of the Chronic Care Model (CCM) for depressed elderly persons in the community could have a positive impact on their mental health. The project involved three integrated phases (i.e. exploring, implementing and evaluating) linked to each other in terms of conceptual definitions, the theoretical model, methodological development, empirical qualitative analysis, theoretical reviews, updating of reviews and dissemination of results, all of which expanded the knowledge base. Overall, our empirical studies revealed that the CCM intervention had positive results due to staff members’ commitment to improving care, their awareness of the need for collaboration and willingness to assume responsibility. From the perspective of the depressed elderly persons, the result indicated their need for support in order to achieve self-management. The lack of continuity of care and the ineffectiveness of the healthcare system resulted in inadequate care. Patients did not participate in decisions about their care and treatment, their values were not respected nor were their specific needs fully met, which is the opposite of patient-centredness. After implementation of the CCM, the evaluation of shared decision-making in care of depressed elderly persons was intended to prevent the violation of human dignity by changing attitudes, increasing understanding by clarifying the care manager’s role and responsibility as well as safeguarding the autonomy of depressed elderly persons. The relation between patients’ experiences of physical health problems and service outcomes, such as patient safety, revealed the need to understand their experiences of living with stigma. The patients wished to be taken seriously and had the impression that healthcare professionals ignored their physical problems. We found a lack of effective team leadership in the community as well as the need to change the delivery system, increase self-management support for depressed elderly persons and promote the participation of their family members. Quality management and action-oriented involvement are necessary in implementation research, as they will promote the professional development of interdisciplinary teams as well as constitute a basis for further research on understanding and improving the care of depressed elderly individuals.

Background:One of the greatest challenges faced by health care systems is the increasing burden of chronic diseases (WHO 2002). Chronic disease management is a systematic approach to the coordination of health care interventions and communication at indiv idual, organizational, regional and national level (Sign 2008). Primary health care and community care are important settings for the prevention of mental health problems among elderly persons living in the community. An innovative approach to user invol vement and evidenced-based care for depressed elderly persons will be employed. This study will use participatory design methods to describe, implement and evaluate. Phase 1 of the project will be based on a qualitative approach, Phase 2 will consist of implementation of the CCM in interdisciplinary teams working in mental health clinics and community health care; and the third Phase 3 will be to evaluate the outcomes of the implemented model as well as the patients' and family members' experiences of th e care provided as well as those of the interdisciplinary teams. The CCM will serve as a frame of reference for interventions at both individual and structural level (Wagner et al. 2001, Bodenheimer et al. 2002ab). The model identifies six interrelated co mponents that are essential for providing quality care to patients with chronic illness. The research questions are:1.What are the patient's subjective experiences of his/her mental health problems? 2.What are the patient's and family members' subjective experience of health care services? 3.How can chronic disease management for persons with depression be improved? 4.How can strategies to support patients' self-management of illness be improved? 5.What do the patients' pathways through the health care sy stem look like? Five senior researchers and one postdoctoral student from four academic disciplines (public health, nursing, social science and education) will collaborate in this research.