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

 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 tailored^b 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

 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 plan—content. 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

 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 adjusted^b to each municipality

 Collaborative care plan—content. 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

 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

Target^b 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

 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

 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