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Table 4 A complex intervention plan developed by the research team and the modifications and new interventions suggested by the focus groups for each recommendation

From: Tailoring interventions to implement recommendations for the treatment of elderly patients with depression: a qualitative study

Recommendation: social contact
Draft plan from the research team Modifications or new interventions from the group sessions Adaptation to municipalities or practices Targeted determinant (see Table 3)
 Collaborative care plan a. Include key personnel, e.g. leaders for voluntary organisations who can help identifying voluntary Such as Centre for volunteers, Centre for healthy life, charity organisations (Lions, Red Cross), congregations and fitness centres Identify key personnel in each municipality Finding volunteers
 Collaborative care plan. Provide a model agreement between the municipality and voluntary organisations that clarifies expectations, responsibilities follow-up and monitoring Provide a model agreement between the municipality and voluntary organisations that clarifies expectations, responsibilities (such as a contact or an office), communications (such as, for instance, a website, neighbourhood/local newspaper, posters), follow-up and monitoring  
 Educational resources. Educate voluntary in communication with depressed patients   
  Collaborative care plan. Inform relatives, use existing local knowledge within the community (e.g. home-based nurse staff, voluntary organisations, congregations) Identify persons who possess local knowledge on voluntary organisations and volunteers
 Collaborative care plan. Include key personnel Such as family, GP, home based nursing services, health centre for the elderly, municipality’s cultural agency, Council or the elderly and the union for retirees.   Lack of awareness of local community/services
 Collaborative care plan. Help to obtain an overview of services in the community Such as obtain an overview in one place, e.g. by the home based nurse services administration, responsible for contacting voluntary organisations for an overview  
  Collaborative care plan. Provide information via brochures, advertisements in the local newspaper, the municipalities’ website Information tailoredb to each community
  Collaborative care plan. Outreach activities (e.g. letter to all over 80, information in the media   Social withdrawal in elderly patients with depression
 Resources for patients and their relatives. Information to patients and their relatives on social contact, alternatives to antidepressants and counselling Such as brochures aimed at patients and their families, contacting elderly who do not attend consultations or their relatives)  
  Collaborative care plan. Describe the role of senior centres and health clinics for the elderly to reduce social withdrawal  
 Resources for GPs and other health care professionals. Provide contact information for physical activity, voluntary organizations, senior centres, etc. e.g. a contact/coordinator of the municipal/district, using brochures Templates for how the municipality could publish contact Lack of connection between the patient and the volunteer
 Collaborative care plan. Create a job description that helps the municipality to find suitable persons who can lead the efforts   Create templates with a job description that each municipality could fit to local routines Requires organisation
 Collaborative care plan. Consider the financial resources to motivate people to take this work   
Recommendation: collaborative care plan
Draft plan from the research team Modifications or new interventions from the group sessions Adaptation to municipalities or practices Targeted determinant (see Table 3)
 Collaborative care plan. Including key personnel in the development of the plan Key personnel such as coordinator/office for approval of health services, GP/GP committees, Community based psychiatric centres, and impose key personnel to help in the development of the plan Template for the plan should be adapted to each municipality and include key personnel Actionable plans with shared ownership increases the plan’s feasibility
 Collaborative care plan. Include The Norwegian Association of Local and Regional Authorities (KS) and local opinion leaders in the work with the plan and presentation of recommendations   
 Collaborative care plan. Help to make it convenient to implement the plan (e.g., to create a comprehensive plan for psychiatry, where seniors also have a place)   
 Collaborative care plan. Help to develop a dissemination and implementation plan   
  Collaborative care plan. The plan must be consistent with the national collaboration reform  
 Collaborative care plan. Exchange experiences (good/bad) across municipalities   
 Online services. Support for electronic communication between health care personnel in the community and specialists if possible    Lack of coordination within municipalities, especially between GPs and other municipal services
 Collaborative care plan. Help to develop a dissemination and implementation plan    Implementation of the plan
 Collaborative care plan—content. Describe the recruitment of care managers to obtain suitable personnel (use local knowledge to identify particularly suitable people)   Provide templates for a job description that could be adapted to each municipality and provide help to identify suitable professionals
 Collaborative care plan—content. Clarify the individual tasks with clear guidelines and support for them to adhere Assign one person to the responsibility for the plan (e.g. CMO) Name the person or the applied role in the system that carry the responsibility for the plan
 Collaborative care plan—development. Include The Norwegian Association of Local and Regional Authorities (KS) and local opinion leaders in the work with the plan and presentation of the recommendations The plan should be politically/administratively anchored  
 Collaborative care plancontent. Help to implement the plan in practice e.g. through regular meetings. If necessary; compel health professionals to implement the plan  
 Collaborative care plan. Arrangements for monitoring and evaluation of the plan (e.g. via notification systems, involving health committee)   
 Collaborative care plan—development. A model plan with a checklist of both the process to make the plan and the content of the plan   
 Online services. Web page with all the resources and recommendations   
 Collaborative care plan. Arrangements for dissemination and implementation of the plan   
Recommendation: depression case manager
Draft plan from the research team Modifications or new interventions from the group sessions Adaptation to municipalities or practices Targeted determinant (see Table 3)
 Outreach visits to GPs. Inform GPs about the concept and evidence supporting the CM, and how referral should be done    A description for how the GP should proceed
 Resources for GPs and other health care professionals—Structured referral forms to case manager, web-based and integrated in journal   Provide templates for referral that can be adjustedb to each municipality
 Collaborative care plancontent. Establish CM services in each municipality and effective referral practices of GPs to CM Consider initiating contact between doctor, patient and CM. CM can be a GP assistant in the GP practice or another appropriate person in primary care  
 Collaborative care plan—content. A plan for support/guidance/counselling for CM    Good relationship between patient and depression case manager
 Educational resources. Training in communication with depressed patients for CMs   
  Educational resources. Inform CM that family members should be involved when necessary  
 Collaborative care plan—content. A plan for support/guidance/counselling for CM e.g. establish groups for CMs, supervised by GPs, psychiatric nurses or specialist health care   If the person is completely alone on the task
 Online services. Integrate recommendations and resources to medical records systems   
Recommendation: counselling
Draft plan from the research team Modifications or new interventions from the group sessions Adaptation to municipalities or practices Targeted determinant (see Table 3)
 Outreach visits to GPs. Discuss physician time constraints and the possibility of extended consultations and additional fees    GPs’ time constraint
 Outreach visits to GPs. Clarify to GPs that older with moderate to severe depression profit from counselling   Targetb and adjust this information to each outreach visit
  Outreach visits to GPs. Consider if other health professionals than GPs can offer counselling Identify personnel that exhibit these skills in each municipality during outreach visits
 Outreach visits to GPs. Emphasize for GPs that we have alternatives to antidepressants for mild depression that are more effective and less harmful    Health professionals believe self-help program is not beneficiary for this population
 Resources for general practitioners and other health care professionals. Resources for counselling (e.g. brief information about self-help programs, physical activity, sleep habits and anxiety coping that can be discussed with patients and caregivers, use simple forms or manuals Resources for general practitioners and other health care professionals. Resources for counselling (e.g. brief information about self-help programs, physical activity, sleep habits and anxiety coping that can be discussed with patients and caregivers, use simple forms or manuals   There is a shortage of this type of service
  Collaborative care plan. Identify services to determine if it is right that the services are missing As part of the plan
  Outreach visits. Identify services to determine if it is right that the services are missing As part of outreach visits
 Resources for general practitioners and other health care professionals. Resources for counselling (e.g. brief information about self-help programs, physical activity, sleep habits and anxiety coping that can be discussed with patients and caregivers, use simple forms or manuals    Lack of skills to provide counselling among GPs and healthcare
 Educational resources. Courses for GPs must merit for the speciality (CME credits) (15 h) and can be a combination of web-based courses and educational meetings   
 Educational resources. E-learning courses and other forms of informing healthcare professionals about the recommendations and in particular techniques for counselling and motivation, Training for GPs should be designed as a clinical topic course and merit for CME credits  
Recommendation: antidepressants in mild depression
Draft plan from the research team Modifications or new interventions from the group sessions Adaptation to municipalities or practices Targeted determinant (see Table 3)
 Outreach visits to GPs. Discuss physician time constraints and the possibility of extended consultations and additional fees    GPs’ time constraint
 Resources for patients and their relatives. Information to patients and their relatives on social contact, alternatives to antidepressants and counselling e.g. information presented in brochures and on websites Information forms that allow the GP to tailor information to patients Patient information that drugs do not help in mild depression
Outreach visits to GPs. Provide evidence for not using antidepressants for mild depression and inform that we have better alternatives    Difficult to reverse a trend where the doctor has been told that they prescribe antidepressants too rarely
 Outreach visits to GPs. Emphasize for GPs the need for grading the severity of depression using appropriate tools, such as MADRS, for diagnosis and follow-up   
 Outreach visits to GPs. Discuss the idea that GPs feel that they are accused of prescribing antidepressants too seldom   
  Resources for GPs and other healthcare professionals. Offer monitoring and feedback to GPs, preferably in groups Use existent groups or discuss with leaders of local GP groups whether new groups could be created
 Educational courses. Provide training in counselling as problem solving therapy, anxiety coping and sleep habits, for instance as e-learning courses    Lack of other types of services makes it difficult to adhere
 Educational courses. Courses for GPs must merit for the speciality (15 h) and can be a combination of web-based courses and meetings   
 Educational courses. E-courses and other courses to inform healthcare professionals about the recommendation, and in particular techniques for counselling and motivation   
 Outreach visits to GPs. Discuss this with GPs. Suggest strategies to avoid prescribing antidepressants    GP wants to “do something”, drugs are simple actions
Recommendation: Antidepressants and psychotherapy in severe and recurrent depression
Draft plan from the research team Modifications or new interventions from the group sessions Adaptation to municipalities or practices Targeted determinant (see Table 3)
 Resources for general practitioners and other health care professionals. Structured referral forms to psychotherapy to private specialists, district based psychiatric centres and old age psychiatry Templates for referral may be adjusted to each municipality GPs do not have this expertise (psychotherapy)
 Resources for patients and their relatives. Information to patients and their families about the combined treatment (psychotherapy and antidepressants)    Elderly are not prioritised for this type of service
 Collaborative care plan—development. Include key personnel in the development of the plan (managers, administrators, specialists in private practices, GPs, GPs’ committees, nurses, specialist care, patients and relatives)   
 Collaborative care plan—content. A clear message in the plan about access to psychotherapy for the elderly with severe depression with community based psychiatric centres and private practitioners   Templates for the description of specialist care adjusted to the municipality and the collaborating specialists/specialist services
 Collaborative care plan—content. State that the recommendations are in accordance with national guidelines e.g. in the media  
 Outreach visits. Clarify that older with moderate to severe depression profit from psychotherapy   
 Educational courses. Training in cognitive therapy for general practitioners and psychiatric nurses for those who want it    Lack of health professionals who can provide this type of service
 Resources for GPs and other healthcare professionals. Structured referral forms to psychotherapy   Templates for referral forms adjusted to each municipality
  1. aFor a comprehensive description of the various items in the intervention plan, please refer to the methods section
  2. bIn this table we use the terms “tailoring”, “targeting” and “adjustment”. We define these terms in the following way: Tailoring: planning interventions/strategies that are designed to achieve desired changes in healthcare practice based on an assessment of determinants of healthcare practice. Targeting: implementation of the tailored intervention for selected GPs, practices or communities (where the determinant could be identified) and not for others (where the determinant could not be identified). Adjustment: modification of the tailored intervention to address determinants that are identified as the tailored intervention is implemented