Standing together at the helm - how employees experience employee-driven innovation in primary care.

Primary care needs to find strategies to deal with today's societal challenges and continue to deliver efficient and high-quality care. Employee-driven innovation is increasingly gaining ground as an accessible pathway to developing successful and sustainable organisations. This type of innovation is characterised by employees being engaged in the innovation process, based on a bottom-up approach. This qualitative study explores employees' experiences of employee-driven innovation at a primary care centre in Sweden. Data are collected by focus group interviews and analysed by inductive qualitative content analysis. The result is presented with the overarching theme "Standing together at the helm" followed by three categories: "Motivating factors for practising employee-driven innovation", "Challenges in practising employee-driven innovation" and "Benefits of employee-driven innovation", including nine subcategories. The study found that employee-driven innovation fosters organisational innovation, empowers employees, and enhances adaptability at personal and organisational levels. This enables individual and collective learning, and facilitates the shaping, development, and adaptation of working methods to meet internal and external requirements. However, new employees encountered difficulty grasping the concept of employee-driven innovation and recognising its long-term advantages. Additionally, the demanding and task-focused environment within primary care posed challenges in sustaining efforts in innovation work. The employees also experienced a lack of external support to drive and implement some innovative ideas.

Process evaluation of the CO-WORK-CARE model: Collaboration and a person-centred dialogue meeting for patients with common mental disorder in primary health care.

RATIONALE: To ensure optimal patient care based on evidence, it is crucial to understand how to implement new methods in practice. However, intervention studies often overlook parts of the implementation process. A comprehensive process evaluation is necessary to understand why interventions succeed or fail in specific contexts and to integrate new knowledge into daily practice. This evaluation examines the full implementation of the Co-Work-Care model in Swedish primary healthcare to identify strengths and weaknesses. AIM: This study aimed to evaluate the process of implementing the CO-WORK-CARE model that focuses on close collaboration and the use of a person-centred dialogue meeting in primary healthcare for patients on sick leave due to common mental disorders. METHOD: The CO-WORK-CARE model emphasises collaboration among the GP, rehabilitation coordinator and care manager, along with person-centred dialogue meetings involving employers. Following UK Medical Research Council guidelines, we conducted a process evaluation. Data from previous studies were reanalysed. We also analysed field notes and meeting notes using Malterud's qualitative method. RESULTS: The evaluation identified key facilitators for model implementation, including regular visits by facilitators and guidance from the research physician. Peer support meetings also bolstered implementation. However, challenges emerged due to conflicts with existing structures and limitations in person-centred dialogue meetings. CONCLUSION: Adapting the CO-WORK-CARE model to Swedish primary care is feasible and beneficial, with collaboration among the care manager, rehabilitation coordinator and GP and person-centred dialogue meetings. Thorough preparations, ongoing facilitator and peer support and integrated information enhanced implementation efficiency, despite challenges posed by existing structures.

How can care managers strengthen health literacy among patients with common mental disorders? A qualitative study.

BACKGROUND: In order for persons with mental illness to be able to promote and preserve their health, sufficient knowledge about health is required. An effective means to improve the health of the patients is to strengthen their health literacy. The aim of this study was to explore how care managers work with health literacy in patients with common mental disorders to help them to better understand and manage their illness. METHOD: A qualitative study was conducted, using written reports from 25 care managers regarding meetings with patients with common mental disorders in the primary care in a Swedish region. The care managers' reports were coded based on Sörensen's four dimensions for the domain "health care" and analysed deductively through systematic text condensation according to Malterud. RESULTS: The care managers described how they worked strategically and continuously with follow-up and wanted to be responsive to the patients' stories. They confirmed the patients' feelings with the goal of creating increased interaction, thereby involving the patients in their own care. The care managers also worked actively to provide well-balanced care at an early stage. Using various tools such as self-assessment instruments, the care manager started from the patient's basic problem, gave support and discussed strategies based on the patient's condition and situation. CONCLUSIONS: The care managers used multifaceted health literacy interventions. They worked in a person-centred, strategic and encouraging manner based on the patient's unique conditions, where sensitivity and adapted information were important aspects. The aim of the interventions was for the patients to become knowledgeable, gain new insights and work independently with their own health.

Promoting health literacy and sense of coherence in primary care patients with long-term impaired work ability-a pilot study.

OBJECTIVE: Evaluate feasibility, partnerships, and study design of intervention to minimise sick leave. DESIGN AND SETTING: The design was a pilot single arm intervention study in primary health care. Outcome measures at follow-ups for each participant were compared with baseline data for the same person. SUBJECTS: Twenty primary health care patients with recurrent or long-term sick leave or health-related unemployment. INTERVENTION: Patient education through interactive study groups that met half a day a week for eight subsequent weeks. Groups were led by experienced but not medically trained facilitators. The intervention was designed to improve participant health literacy, sense of coherence, health-related quality of life, and patient involvement in healthcare. MAIN OUTCOME MEASURES: Primary outcome was the level of sick leave. Sick leave data were obtained from medical records when available, otherwise patient reported. Secondary outcomes regarding health literacy, sense of coherence, and health-related quality of life were measured with validated questionnaires at baseline and follow-ups. RESULTS: Level of sick leave decreased significantly and participation in work preparatory activities increased during follow-up. Health literacy, sense of coherence (subscale sense of meaningfulness), and health-related quality of life (subscale social functioning) showed statistically significant improvement. Intervention, partnerships, and study design were feasible. CONCLUSION: An educational programme, conducted in cooperation between primary health care and partners outside the healthcare system, was feasible and showed an impact on sick leave, health literacy, sense of coherence, and health-related quality of life.KEY FINDINGSA pilot study to evaluate an educational programme with study groups conducted in cooperation between primary health care and partners outside the healthcare system showed good feasibility.Sick leave decreased significantly six months after baseline.Health literacy, sense of coherence (subscale sense of meaningfulness), and health-related quality of life (subscale social function) improved significantly 6 months after baseline.

How can a care manager at the primary care centre support foreign-born female patients suffering from common mental disorders? - An interview study.

BACKGROUND: Difficulty in communicating can lead to stressful situations both for foreign-born female patients suffering from common mental disorders (CMDs) and for the health care professionals. AIM: The aim of the study was to explore how foreign-born female patients with CMDs experienced their health care encounters and how they perceived a care manager could be a support during their illness, as well as to explore the care managers' perceptions and experiences concerning this group. METHODS: A qualitative method with semi-structured interview was chosen. The data were analysed with systematic text condensation. The study was conducted in primary care in western Sweden. Eight Persian-speaking female patients were recruited by the snowball method and participated in the study. Furthermore, nine care managers participated. RESULTS: Foreign-born female patients felt shame and anxiety because of language difficulties, interpreter presence, mental illness, and feelings of dependency. The care managers and the patients felt that physical meetings, access to translated assessment scales and female telephone interpreters, and early and continuous contact and access to health care personnel with a similar cultural background could facilitate communication. CONCLUSION: In order to facilitate mutual understanding and knowledge, accessibility and continuity of health care are needed to enable foreign-born female patients with CMD to support their own health development. Female interpreters, telephone interpreting, translated scales, and telephone contacts combined with face-to-face visits could facilitate communication.

Cost-effectiveness of a care manager collaborative care programme for patients with depression in primary care: 12-month economic evaluation of a pragmatic randomised controlled trial.

OBJECTIVES: To study the cost-effectiveness of a care manager organization for patients with mild to moderate depression in Swedish primary care in a 12-month perspective. METHODS: Cost-effectiveness analysis of the care manager organization compared to care as usual (CAU) in a pragmatic cluster randomised controlled trial including 192 individuals in the care manager group and 184 in the CAU group. Cost-effectiveness was assessed from a health care and societal perspectives. Costs were assessed in relation to two different health outcome measures: depression free days (DFDs) and quality adjusted life years (QALYs). RESULTS: At the 12-month follow-up, patients treated at the intervention Primary Care Centres (PCCs) with a care manager organization had larger health benefits than the group receiving usual care only at control PCCs. Mean QALY per patient was 0.73 (95% CI 0.7; 0.75) in the care manager group compared to 0.70 (95% CI 0.66; 0.73) in the CAU group. Mean DFDs was 203 (95% CI 178; 229) in the care manager group and 155 (95% CI 131; 179) in the CAU group. Further, from a societal perspective, care manager care was associated with a lower cost than care as usual, resulting in a dominant incremental cost-effectiveness ratio (ICER) for both QALYs and DFDs. From a health care perspective care manager care was related to a low cost per QALY (36,500 SEK / €3,379) and DFD (31 SEK/€3). LIMITATIONS: A limitation is the fact that QALY data was impaired by insufficient EQ-5D data for some patients. CONCLUSIONS: A care manager organization at the PCC to increase quality of care for patients with mild-moderate depression shows high health benefits, with no decay over time, and high cost-effectiveness both from a health care and a societal perspective. Trial registration details: The trial was registered in ClinicalTrials.com ( https://clinicaltrials.gov/ct2/show/NCT02378272 ) in 02/02/2015 with the registration number NCT02378272. The first patient was enrolled in 11/20/2014.

The care manager meeting the patients' unique needs using the care manager model-A qualitative study of experienced care managers.

BACKGROUND: Implementation of a care manager in a collaborative care team in Swedish primary care via a randomized controlled trial showed successful outcome. As four years have elapsed since the implementation of care managers, it is important to gain knowledge about the care managers' long-term skills and experiences. The purpose was to examine how long-term experienced care managers perceived and experienced their role and how they related to and applied the care manager model. METHOD: Qualitative study with a focus group and interviews with nine nurses who had worked for more than two years as care managers for common mental disorders. The analysis used Systematic Text Condensation. RESULTS: Four codes arose from the analysis: Person-centred; Acting outside the comfort zone; Successful, albeit some difficulties; Pride and satisfaction. The care manager model served as a handrail for the care manager, providing a trustful and safe environment. Difficulties sometimes arose in the collaboration with other professionals. CONCLUSION: This study shows that long-term experience of working as a care manager contributed to an in-depth insight and understanding of the care manager model and enabled care managers to be flexible and act outside the comfort zone when providing care and support to the patient. A new concept emerged during the analytical process, i.e. the Anchored Care Manager, which described the special competencies gained through experience. TRIAL REGISTRATION: NCT02378272  Care Manager-Coordinating Care for Person Centered Management of Depression in Primary Care (PRIM-CARE).

Prognostic factors for future mental, physical and urogenital health and work ability in women, 45-55 years: a six-year prospective longitudinal cohort study.

BACKGROUND: Impaired health due to stress is a common cause of long-term illness in women aged 45-55 years. It is a common cause for visits to primary health care (PHC) and may influence work-ability. The aim of this study was to investigate prognostic factors for future mental, physical and urogenital health as well as work-ability in a population of average women aged 45-55 years. METHODS: This longitudinal cohort study initially assessed 142 women from PHC centers in southwestern Sweden. One houndred and ten accepted participation and were followed for 6 years. They were assessed using the self-reported questionnaires: the Menopause Rating Scale (MRS), the Montgomery-Asberg Depression Rating Scale (MADRS-S), the Short-Form Health Survey (SF-36). Descriptive data are presented of health, education, relationships and if they are working. Multicollinearity testing and logistic regression were used to test the explanatory variables. RESULT: Severity of symptoms in the MRS somatic and urogenital domains decreased while they increased in the psychological and depressive domains. Having tertiary education was associated with decreased overall mental health, vitality and social role functioning. Living with a partner was associated with increased physical role functioning, social role functioning and emotional role functioning. CONCLUSION: Quality of life seems to be enhanced by a good relationship with the partner, social support and work/life balance. Therefore, to improve women health women should early discuss ways in which these issues can be incorporated as they pursue their academic or career goals. Hence, we emphasize the importance of supporting women to gain increased awareness about a healthy life balance and to have realistic goals in work as well as in their social life.

The experiences of care managers and rehabilitation coordinators of a primary care intervention to promote return to work for patients with common mental disorders: a qualitative study.

BACKGROUND: In an earlier study, PRIM-CARE RCT, a care manager implementation at the primary care centre showed improved return to work and reduced sick leave for patients with CMD. To further improve return to work, the project Co-Work-Care added a person-centered dialogue meeting between the patient, the employer and the rehabilitation coordinator, preceded by an increased collaboration between care manager, rehabilitation coordinator and GP. In this first qualitative study of the Co-Work-Care project, we explored how care managers and rehabilitation coordinators experienced the Co-Work-Care model. The purpose of this study was to explore care managers' and rehabilitation coordinators' perceptions and experiences of a close collaboration and the use of the person-centred dialogue meeting. METHODS: From an ongoing RCT with 20 primary care centres, care managers (CMs) (n = 13) and rehabilitation coordinators (RCs) (n = 12) participated in a qualitative study with focus groups. The study was conducted in the primary health care in a Swedish region. The data was analysed with Systematic Text Condensation by Malterud. RESULTS: Seven codes describing the participants' experiences of the Co-Work-Care model were identified: 1) The importance of collaboration at the primary care centre, 2) Collaboration and division of roles between the RC and the CM, 3) Collaboration with the General practitioner (GP), 4) The person-centred dialogue meeting, 5) Initiating the person-centred dialogue meeting, 6) The person-centred dialogue meeting to improve collaboration with the employer, and 7) The person-centred dialogue meeting to teach about the return to work process. CONCLUSION: The increased collaboration within the Co-Work-Care model created a common picture and understanding of the patient's situation. The person-centred dialogue meeting in the rehabilitation process became a bridge between the employer and the patient. TRIAL REGISTRATION: NCT03250026 (registered August 15, 2017).

Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs' experiences.

Objective: Explore general practitioners' (GPs') views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases. Design: Qualitative content analysis of five focus-group discussions. Setting: Primary health care centers in the Region of Västra Götaland and Dalarna County, Sweden. Subjects: 29 GPs. Main outcome measures: GPs' views and experiences of care managers for patients with depression. Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases. Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members' roles must be clear. KEY POINTS A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs' experiences of this kind of collaborative care is limited. GPs find that care managers provide support for patients and security and relief for GPs. GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager. GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.

Clinical effectiveness of care managers in collaborative care for patients with depression in Swedish primary health care: a pragmatic cluster randomized controlled trial.

BACKGROUND: Depression is one of the leading causes of disability and affects 10-15% of the population. The majority of people with depressive symptoms seek care and are treated in primary care. Evidence internationally for high quality care supports collaborative care with a care manager. Our aim was to study clinical effectiveness of a care manager intervention in management of primary care patients with depression in Sweden. METHODS: In a pragmatic cluster randomized controlled trial 23 primary care centers (PCCs), urban and rural, included patients aged ≥ 18 years with a new (< 1 month) depression diagnosis. Intervention consisted of Care management including continuous contact between care manager and patient, a structured management plan, and behavioral activation, altogether around 6-7 contacts over 12 weeks. Control condition was care as usual (CAU). OUTCOME MEASURES: Depression symptoms (measured by Mongomery-Asberg depression score-self (MADRS-S) and BDI-II), quality of life (QoL) (EQ-5D), return to work and sick leave, service satisfaction, and antidepressant medication. Data were analyzed with the intention-to-treat principle. RESULTS: One hundred ninety two patients with depression at PCCs with care managers were allocated to the intervention group, and 184 patients at control PCCs were allocated to the control group. Mean depression score measured by MADRS-S was 2.17 lower in the intervention vs. the control group (95% CI [0.56; 3.79], p = 0.009) at 3 months and 2.27 lower (95% CI [0.59; 3.95], p = 0.008) at 6 months; corresponding BDI-II scores were 1.96 lower (95% CI [- 0.19; 4.11], p = 0.07) in the intervention vs. control group at 6 months. Remission was significantly higher in the intervention group at 6 months (61% vs. 47%, p = 0.006). QoL showed a steeper increase in the intervention group at 3 months (p = 0.01). During the first 3 months, return to work was significantly higher in the intervention vs. the control group. Patients in the intervention group were more consistently on antidepressant medication than patients in the control group. CONCLUSIONS: Care managers for depression treatment have positive effects on depression course, return to work, remission frequency, antidepressant frequency, and quality of life compared to usual care and is valued by the patients. TRIAL REGISTRATION: Identifier: NCT02378272 . February 2, 2015. Retrospectively registered.

Creating a safety net for patients with depression in primary care; a qualitative study of care managers' experiences.

OBJECTIVE: The aim of this study was to explore nurses' experiences and perceptions of working as care managers at primary care centers. DESIGN: Qualitative, focus group study. Systematic text condensation was used to analyze the data. SETTING: Primary health care in the region of Västra Götaland and region of Dalarna in Sweden. SUBJECTS: Eight nurses were trained during three days including treatment of depression and how to work as care managers. The training was followed by continuous support. MAIN OUTCOME MEASURES: The nurses' experiences and perceptions of working as care managers at primary care centers. RESULTS: The care managers described their role as providing additional support to the already existing care at the primary care center, working in teams with a person-centered focus, where they were given the opportunity to follow, support, and constitute a safety net for patients with depression. Further, they perceived that the care manager increased continuity and accessibility to primary care for patients with depression. CONCLUSION: The nurses perceived that working as care managers enabled them to follow and support patients with depression and to maintain close contact during the illness. The care manager function helped to provide continuity in care which is a main task of primary health care. Key Points The care managers described their role as an additional support to the already existing care at the primary care center. • They emphasized that as care managers, they had a person-centered focus and constituted a safety net for patients with depression. • Their role as care managers enabled them to follow and support patients with depression over time, which made their work more meaningful. • Care managers helped to achieve continuity and accessibility to primary health care for patients with depression.

Professionals' experiences of what affects health outcomes in the sick leave and rehabilitation process-A qualitative study from primary care level.

OBJECTIVE: To explore frontline employees' experiences of how to create a purposeful sick leave and rehabilitation process (SRP) with the best interest of patients' long-term health in focus. METHODS: Qualitative design based on focus group interviews in a primary care context in Region Västra Götaland, Sweden. Strategically selected professionals from different SRP organizations discussed sick leave outcomes and the rehabilitation process. Analysis was performed with Systematic text condensation. SUBJECTS: General practitioners (n = 6), rehabilitation coordinators and/or healthcare professionals from primary healthcare (n = 13), caseworkers from the Social Insurance Agency, the Employment Agency, and Social Services (n = 12). RESULTS: The outcome of the SRP was described to depend upon the extent to which the process meets patients' bio-psycho-social needs. Aspects considered crucial were: 1) early bio-psycho-social assessments, including medical specialist consultations when needed, 2) long-term realistic planning of sick leave and rehabilitation alongside medical treatment, 3) access to a wide range of early rehabilitative and supportive interventions, including situation-based, non-medical practical problem solving, and 4) trusting relationships over time for all involved professions and roles to maximize process quality and person-centeredness. A gap between the desired scope of the SRP and existing guidelines was identified. CONCLUSION: Interviewees perceived that successful outcomes from the sick leave and rehabilitation process in a primary care context depend on consensus, person-centeredness, and relationship continuity for all involved professions. An extended process scope and relationship continuity for all involved professionals were suggested to improve process outcomes.

Rehabilitation cooperation and person-centred dialogue meeting for patients sick-listed for common mental disorders: 12 months follow-up of sick leave days, symptoms of depression, anxiety, stress and work ability - a pragmatic cluster randomised controlled trial from the CO-WORK-CARE project.

OBJECTIVES: To study whether early and enhanced cooperation within the primary care centres (PCC) combined with workplace cooperation via a person-centred employer dialogue meeting can reduce days on sick leave compared with usual care manager contact for patients on sick leave because of common mental disorders (CMD). Secondary aim: to study lapse of CMD symptoms, perceived Work Ability Index (WAI) and quality of life (QoL) during 12 months. DESIGN: Pragmatic cluster randomised controlled trial, randomisation at PCC level. SETTING: 28 PCCs in Region Västra Götaland, Sweden, with care manager organisation. PARTICIPANTS: 30 PCCs were invited, 28 (93%) accepted invitation (14 intervention, 14 control) and recruited 341 patients newly sick-listed because of CMD (n=185 at intervention, n=156 at control PCCs). INTERVENTION: Complex intervention consisting of (1) early cooperation among general practitioner (GP), care manager and a rehabilitation coordinator, plus (2) a person-centred dialogue meeting between patient and employer within 3 months. CONTROL GROUP: regular contact with care manager. MAIN OUTCOME MEASURES: 12 months net and gross number of sick leave days at group level. SECONDARY OUTCOMES: 12 months depression, anxiety, stress symptoms, perceived WAI and QoL (EuroQoL-5 Dimensional, EQ-5D). RESULTS: No significant differences were found between intervention and control groups concerning days of sick leave (intervention net days of sick leave mean 102.48 (SE 13.76) vs control 96.29 (SE 12.38) p=0.73), return to work (HR 0.881, 95% CI 0.688 to 1.128), or CMD symptoms, WAI or EQ-5D after 12 months. CONCLUSIONS: It is not possible to speed up CMD patients' return to work or to reduce sick leave time by early and enhanced coordination among GP, care manager and a rehabilitation coordinator, combined with early workplace contact over and above what 'usual' care manager contact during 3 months provides. TRIAL REGISTRATION NUMBER: NCT03250026.

Anxiety and depression in obese and normal-weight individuals with diabetes type 2: a gender perspective.

BACKGROUND: Obesity is a problem that is increasing worldwide, leading to an increased incidence of type 2 diabetes mellitus (T2DM). Depression is more common among individuals with diabetes, and they are more likely than non-diabetic individuals to experience emotional problems. People with both T2DM and obesity bear an additional emotional burden, which affects their quality of life. OBJECTIVES: To describe the prevalence of symptoms of anxiety and depression in groups of obese and normal-weight individuals with T2DM who are undergoing primary care and to investigate possible differences between the groups and between genders. METHOD: Three hundred and thirty-nine patients with T2DM from nine primary-care centres participated in a cross-sectional study (n = 180 + 159). The response rate was 67%. The Hospital Anxiety and Depression Scale (HADS) and the Beck Depression Inventory - second edition (BDI-II) were employed to estimate the patients' symptoms of depression and anxiety. RESULTS: An association between T2DM, obesity and depression was observed in both genders. More than one in three women and one in five men with T2DM and obesity exhibited symptoms of anxiety or depression. In the normal-weight group, the females presented more symptoms of anxiety than did their male counterparts. CONCLUSION: In primary healthcare, the fact that both obese men and women with T2DM are at increased risk of anxiety and depression is an important finding, which must be recognised and considered in the course of primary healthcare consultations. Meeting the unique needs of each individual requires an understanding of both laboratory data and the individual's emotional status.

Long-term effect of a care manager on work ability for patients with depression - the PRIM-CARE RCT.

BACKGROUND: Collaborative care with a care manager in primary care improves care. OBJECTIVE: To study whether care manager support leads to improved work ability, decreased job strain and reduced time of sick leave among primary care patients with depression. METHODS: A clinical effectiveness study of care managers for depression patients seeking care in primary care was conducted in a RCT 2014 -2016. Patients in the intervention group were assigned a care manager. In the 12-month follow-up, patients with employment (n = 269; intervention n = 142, control n = 127) were studied concerning work ability, job strain and sick leave. RESULTS: An association was shown between reduction of depressive symptoms and improved work ability for the entire group. At 12-month follow-up a statistically significant difference of reduction of depressive symptoms was seen between the groups (MADRS-S: intervention 10.8 vs control 13.1, p = 0.05) as well as increased quality of life (EQ-5D: intervention 0.77 vs control 0.70, p = 0.04). In the intervention group, a concordance was found between the patient's prediction of return to work and the actual return to work (91%for intervention and 68 %for control group, p = 0.047). CONCLUSIONS: Compared to usual care, the care manager does not seem to further improve perception of work ability, job strain or perception of social support per se among the patients despite a long-term effect on depression symptoms. The lack of a long-term effect regarding these aspects may be due to the fact that care manager support was only provided during the first three months.

Experiences of patients with common mental disorders concerning team-based primary care and a person-centered dialogue meeting: An intervention to promote return to work.

OBJECTIVES: Common mental disorders in combination with work-related stress are widespread in the western world, not least in Sweden. Various interactive factors, primarily work-related, have impact on the return to work process, for example; a supportive communicative function between the person on sick leave and the employer may facilitate this process. The aim was to investigate experiences of being part of a collaborative care model including a person-centered dialogue meeting with the employer and with a rehabilitation coordinator as the moderator. METHODS: A qualitative design based on individual interviews with 13 persons diagnosed with common mental disorders who participated in an extensive collaborative care model, called the Co-Work-Care model. Persons were recruited as a heterogeneous sample with respect to age, gender, work background, and time since the intervention. All interviews were analyzed with Systematic Text Condensation. RESULTS: Five codes synthesized the results: 1) A feeling of being taken care of, 2) Collaboration within the team was perceived as supportive, 3) An active and sensitive listener, 4) Structure and planning in the dialogue meeting, 5) The person-centered dialogue meeting was supportive and provided increased understanding. CONCLUSIONS: Participants experienced the close collaborative contact with the care manager and the rehabilitation coordinator as highly valuable for their rehabilitation process. Participants valued a well-structured dialogue meeting that included initial planning and a thorough communication involving the patient, the employer, and coordinator. Further, participants appreciated having an active role during the meeting, also empowering the return to work process.

Symptom patterns in patients newly sick listed for common mental disorders and associations with work-related and socioeconomic factors: a cross-sectional study in Swedish primary care.

OBJECTIVE: The aim was to determine symptom patterns of depression, anxiety and stress-related mental disorders in newly sick listed due to common mental disorders in Swedish primary care patients and to examine associations with sick leave diagnosis, also in relation to socioeconomic, work-related and demographic factors. DESIGN: Cross-sectional study. SETTING: Primary care in western Sweden. PARTICIPANTS: From a randomised controlled trial, patients aged 18-67, seeking primary care and on sick leave due to depression, anxiety and/or mental stress, in total 341 individuals, during 2018-2020. PRIMARY OUTCOME MEASURES: Patterns of depressive, anxiety and stress symptoms measured via self-assessment questionnaires (Montgomery Asberg Depression Rating Scale-Self (MADRS-S), General Anxiety Disorder Scale-7 (GAD-7), Karolinska Exhaustion Disorder Scale (KEDS)), sick leave diagnosis, perception of Work Ability Index and job strain via the job strain model. RESULTS: A combination of high levels of depressive and stress-related symptoms was more frequent than single symptom clusters among persons with common mental disorders (CMD) on sick leave: 7% of the patients had scores above cut-off for one of the instruments MADRS-S, GAD-7 and KEDS, 12% above cut-off for two and 80% had above cut-off for all three instruments. There was no significant association between low socioeconomic status, high-job strain or working in healthcare/education and having scores above cut-off level for two or more of the instruments. Only perception of own poor work ability showed association with having scores above cut-off level for all three of the assessment instruments of CMD (OR 9.45, 95% CI 2.41 to 37.04). CONCLUSION: The diagnosis on the sick certificate is not always congruent with the dominating symptom score level. In patients sick-leaved for CMDs, possible negative factors such as low socioeconomic status, low social support, high-work strain or working in healthcare/education sector did not show significant associations with self-assessment instruments of anxiety, depression and stress. Only patient's perception of own poor work ability was associated with high scores on all three domains. TRIAL REGISTRATION NUMBER: NCT03250026.

GPs' experiences of a collaborative care model for patients with common mental disorders who need sick leave certification: a qualitative study.

BACKGROUND: GPs are an important part of collaboration around patients with common mental disorders (CMD) in primary care. The Co-Work-Care model was implemented to further improve collaboration, and emphasised working more closely with patients through active dialogues among care managers, rehabilitation coordinators, and GPs. This enhanced collaborative model also included a person-centred dialogue meeting with patients' employers. AIM: The aim of this study was to explore GPs' experiences of the Co-Work-Care model, an organisation of collaborative care at the primary care centre (PCC) that includes a person-centred dialogue meeting in the care of patients with CMD who need sick leave certification. DESIGN & SETTING: Qualitative individual and group interviews were conducted with Swedish GPs with experience of the Co-Work-Care trial where the PCC was an intervention PCC with the enhanced collaboration model. METHOD: GPs were sampled purposefully from different Co-Work-Care intervention PCCs in Sweden. Focus group and individual, in-depth semi-structured interviews were conducted. All interviews were analysed by systematic text condensation (STC), according to Malterud. RESULTS: The following three codes describing the GPs' experiences of working in the Co-Work-Care model were identified: (1) a structured work approach; (2) competency of the care manager and the rehabilitation coordinator; and (3) gaining control through close collaboration. CONCLUSION: Overall, GPs' experience was that the enhanced collaboration reduced their workload and enabled them to focus on medical care. Patient care was perceived as safer and more effective. These advantages may result in higher quality in medical and rehabilitation decisions, as well as a more sustainable and less stressful work situation for GPs.

Clinical effectiveness of care managers in collaborative primary health care for patients with depression: 12- and 24-month follow-up of a pragmatic cluster randomized controlled trial.

BACKGROUND: In previous studies, we investigated the effects of a care manager intervention for patients with depression treated in primary health care. At 6 months, care management improved depressive symptoms, remission, return to work, and adherence to anti-depressive medication more than care as usual. The aim of this study was to compare the long-term effectiveness of care management and usual care for primary care patients with depression on depressive symptoms, remission, quality of life, self-efficacy, confidence in care, and quality of care 12 and 24 months after the start of the intervention. METHODS: Cluster randomized controlled trial that included 23 primary care centers (11 intervention, 12 control) in the regions of Västra Götaland and Dalarna, Sweden. Patients ≥18 years with newly diagnosed mild to moderate depression (n = 376: 192 intervention, 184 control) were included. Patients at intervention centers co-developed a structured depression care plan with a care manager. Via 6 to 8 telephone contacts over 12 weeks, the care manager followed up symptoms and treatment, encouraged behavioral activation, provided education, and communicated with the patient's general practitioner as needed. Patients at control centers received usual care. Adjusted mixed model repeated measure analysis was conducted on data gathered at 12 and 24 months on depressive symptoms and remission (MADRS-S); quality of life (EQ5D); and self-efficacy, confidence in care, and quality of care (study-specific questionnaire). RESULTS: The intervention group had less severe depressive symptoms than the control group at 12 (P = 0.02) but not 24 months (P = 0.83). They reported higher quality of life at 12 (P = 0.01) but not 24 months (P = 0.88). Differences in remission and self-efficacy were not significant, but patients in the intervention group were more confident that they could get information (53% vs 38%; P = 0.02) and professional emotional support (51% vs 40%; P = 0.05) from the primary care center. CONCLUSIONS: Patients with depression who had a care manager maintained their 6-month improvements in symptoms at the 12- and 24-month follow-ups. Without a care manager, recovery could take up to 24 months. Patients with care managers also had significantly more confidence in primary care and belief in future support than controls. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02378272. Submitted 2/2/2015. Posted 4/3/2015.