A collaborative primary and mental health care model with psychologist and psychiatrist working in GP practices: Process evaluation of the implementation, challenges, and sustainability

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There is, however, a lack of empirical evidence regarding the benefits of collaborative care in Norway. This study, part of a larger research project, examined the adaptation and implementation of a successful Canadian collaborative care model developed in Hamilton, Ontario, in three Norwegian GP practices located in different boroughs of Oslo, Norway's largest city. Aims To evaluate the required adaptations, implementation, challenges, and sustainability of the Hamilton model within the Norwegian context. Methods The overarching study was a cluster-randomised trial testing the adapted model in three urban GP practices over an 18-month period, with three additional GP practices from the same boroughs serving as control groups. Each intervention site included a half-time clinical psychologist from the local community mental health centre and a psychiatrist who visited for two hours each week. The project also aimed to extend collaboration to other health and community services within each borough. This paper evaluates the implementation of the project's intervention arm, using inductive thematic analysis of documents from all of the project’s phases and following recommendations for process evaluation of complex interventions. Results The model's core component—collaboration between GPs and mental health specialists—was successfully implemented. Participating GPs appreciated the convenient access to mental health specialists to assist with managing mental health problems, although they faced challenges in finding time for collaboration. However, health policy restrictions on providing financial support for co-located collaborative care rendered the model unsustainable beyond the trial period and impeded its expansion to further GP practices. Conclusions The model was successfully implemented and viewed as an improvement in healthcare delivery. If such a model is to be sustained, adjustments must be made to align it with available resources, and reimbursements are needed for collaborative activities in GP practices. It also requires a recognition by funders and planners of the benefits of co-locating specialised mental health specialists within GP practices. Collaborative care mental health general practice implementation sustainability Figures Figure 1 Figure 2 Background The needs for collaborative mental health care The role of general practitioner (family physician) in delivering mental health care General practitioners (GP) plays a key role in delivering mental health care in any health care system ( 1 ), seeing a larger proportion of patients with mental illness than specialised mental health services ( 2 , 3 ). Early intervention, and continuity in the GP-patient relationship are significantly associated with lower use of out-of-hours services, fewer acute hospital admissions, lower mortality rates, and reduced pressure on specialized mental health services ( 4 , 5 ). However, for GPs who have busy schedules, usually seeing twenty or more patients per day, while also carrying financial responsibility for employees working in their practice ( 6 ), identifying mental disorders ( 7 – 10 ) can be challenging, especially when there are concurrent or related physical issues ( 8 , 11 ). In Norway, as elsewhere, there is acceptance of the value of better collaboration between GPs and specialised mental health services ( 12 – 14 ). GPs refer patients needing specialist assessment or treatment and will then collaborate in providing treatment, but often face problems in accessing these services. Studies have demonstrated, however, that GPs who have better access to mental health specialists demonstrate improved skills, knowledge, and confidence when treating patients with mental disorders ( 15 – 18 ). Improving collaboration with patients and their families can also ease the problems posed by fragmented health services ( 16 ). Models of collaborative care One solution to these challenges is to integrate mental health professionals within primary care settings (collaborative care). Collaborative care is used to describe “the process where primary care and mental health providers share resources, expertise, knowledge, and decision-making to ensure that primary care populations receive person-centred, effective, and cost-effective care in the most convenient location and in the most timely and well-coordinated manner possible.” ( 19 ). It usually involves complex interventions ( 20 ), with several interacting components, such as multiple services or teams, various professions, individuals with different competencies, and the completion of multiple tasks related to assessment and treatment. Evidence-informed principles for designing collaborative care include the co-location or close physical proximity of collaborators collaborative relationships, shared goals and a structured organizational framework for the collaboration ( 19 , 21 – 23 ). Although various collaborative care approaches have been described and evaluated, systematic knowledge about the results and experiences of collaboration in Norway is limited. But one successful model based on these principles is the Hamilton Family Health Team’s (HFHTs) model of collaborative care, in Ontario, Canada, which has now been in place for 30 years ( 24 ). The Hamilton Family Health Team (HFHT) Model The Hamilton Family Health Team now includes 180 physicians in 83 practices in a city of 500,000 in Southern Ontario, Canada. ( 23 , 24 ). Each practice has developed a multidisciplinary team that is summarized in Table 1 . Each team includes one or more family physicians, nurses, mental health counsellors, a visiting consulting psychiatrist, and other part-time health professionals (pharmacist, nutritionist, physiotherapist, occupational therapist) who may also play a role in providing mental health care. Team members are co-located in the Family Physicians’ offices and provide assessments, treatment and therapy, health teaching, relapse prevention and linkage with community services, for people presenting with a comprehensive range of problems. The goal is to provide accessible and comprehensive health care close to where the patient lives, with minimal fragmentation of care. The Hamilton FHT - and other collaboration approaches based on this model – has demonstrated many benefits for patients and service providers ( 24 , 25 ). We selected this model to see if it could be adapted to and implemented in the Norwegian context. Table 1 The adapted Norwegian collaborative care model compared to the model of Hamilton Family Health Teams – Mental Health Program (MHC = mental health counsellor, CMHC = community mental health centre) Component Hamilton Family Health Teams – Mental Health Program (HFHT) Agreed adapted collaborative care model for implementation in three Norwegian GP practices Aims Improve collaboration between local mental health practitioners and primary care services and improve Family Physicians competencies and skills. Strengthen the GP practice’s health care for patients with mental and comorbid disorders, study the benefits of collaborative care teams, and adjust the model based on the results of the project. Organization HFHT is a separate organization with a pool of different professionals who are working in or visiting FP practices. No new organization established. The collaborating services decide how much resources they use in the collaboration. Financing of care and collaboration HFHT has public financing from the Ontario Ministry of Health. FPs have public funding on a capitation basis (monthly sum per patient). For both FPs and HFHT this funding supports collaboration. No extra or external funding for the collaborating services, they used their own resources. Psychologists and psychiatrist paid by CMHC. GP practice cover costs for office space and access to patient electronic records. Applications to the national health authorities for financial reimbursements during the project. Agreement Agreement between GP practice and HFHT is integrated within a common governance framework with Ontario Ministry of Health. The participating services (GPs, CMHC, borough services) agreed to participate in implementing the collaborative care model for an 18-months test, waiting to decide if it then would be prolonged. Core component Integration of mental health counsellors and visiting psychiatrist in GP practices Integration of clinical psychologist and psychiatrist into GP practices. Co-location or close location. Clinical staffing per GP/practice 1–6 GPs at each practice 0.25–0.30 mental health counsellor/GP 1 MHC per 7000 GP patients. Access to dietician, pharmacist, addiction specialists, child/adolescent specialists, others 3–4 GPs at each practice (each with ca. 1000 patients) 0.13–0.17 clinical psychologist specialist per GP 0.05 psychiatrist per GP practice 1 psychologist specialist per 8000 GP patients. Ad hoc access to addiction specialists, child/adolescent specialists. Competence of the main mental health worker in the collaboration MHC: Nurse or master-degree social worker with experience from working in the mental health services. Experienced consultant psychiatrist. Clinical psychologist specialists and consultant psychiatrist with extensive experience from mental health services. IT/patient records GP practice electronic patient records GP practice electronic patient records Collaboration within GP practice Referrals from GP to MHC/psychiatrist, ad hoc discussions, joint sessions. MHC provide crisis interventions, short-term treatments, family support, groups. Psychiatrist provides medication review and guidance, and consultation on complex patients. Referrals from GP to psychologist/psychiatrist, ad hoc discussions, joint sessions. Psychologist provides assessments and short-term therapies. Psychiatrist provides medication review and guidance, and consultation on complex patients. Collaboration with other primary care or other specialised mental health care MHC informs and link patients to other community resources, help with referrals to mental health services Contact with other primary care providers in meetings or when requested. Psychologist linking patients to other community resources, help with referrals to other specialised mental health services Care coordination By GP or mental health counsellor GP is care-coordinator for the patients Training and supervision Training by HFHT when starting to work in HFHT. Regular clinical and administrative meetings in HFHT. Acquired clinical and collaborative competence. Information on the HFHT model from visiting and literature. Mutual discussions. No external supervision. Administration Central staff and location of HFHT Meetings in GP practice and the CMHC project group Insert Table 1 here The Norwegian health services Health care in Norway is publicly funded, other than small co-payments for services provided in primary care ( 26 , 27 ). Municipalities are responsible for organizing and providing primary health services, which includes GP services, home nursing, care for the elderly, rehabilitation, and primary mental health services. Specialised mental health services, along with general hospitals, are funded through health trusts administered through four regional health authorities. This split in funding increases the need for better collaboration between the mental health and primary care sectors. Community mental health centres (CMHCs) are mandated to collaborate with GPs and be available for consultation, but there is limited knowledge about the effects of these collaborations or the models that are employed. Norway’s patient-list system, managed by the Norwegian Health Economics Administration, gives all Norwegians the right to a permanent GP, and 96% of the population were registered with one in 2016. The average GP looks after 1000–1500 people, with approximately 1 family physician (full or part-time) per 1000 population. The majority of GPs in Norway are self-employed with nearly one third of their income coming from the local municipality based on the number of patients on their list, two third coming from the Norwegian Labour and Welfare Administration as fee-for-services for patient contacts reported with codes from the International Classification of Primary Care version 2 (ICPC-2), and the remainder from a modest co-payment for each consultation that is paid by the patient. A small but increasing number of GPs in Norway are now fully salaried. The current study Setting The three Oslo boroughs (Alna, Grorud, Stovner) where this study was conducted, had a total population of 108 000 and were served by 85 GPs in 20 practices. Each borough had a range of primary care services, including general nurses, mental health workers, and local substance abuse care. Care is provided in the patient’s home when necessary, and the city of Oslo also has clinics in Emergency Rooms operating 24/7. Social services, employment services and social security are provided by the government’s New Employment and Welfare Administration agency. The specialised mental health services for the boroughs are provided by a CMHC for adults, child and adolescent mental health services (CAMHS) and other departments of the Mental Health Services at the Akershus University Hospital. The CMHC has outpatient clinics, mobile teams and inpatient units. In the three boroughs, the usual collaboration between GPs and specialised mental health services involved referring patients to each other and providing services in separate locations, rarely meeting with each other or seeing a patient together. A national survey conducted in 2018 revealed that GPs felt that collaboration with CMHCs had significantly decreased since 2014, after two decades of consistent improvement, and that the level of collaboration in these three boroughs was below the national average ( 28 ). The cluster-randomised controlled trial of the adapted collaborative care model The adapted Oslo model (described in more detail under Results) was similar to that employed in Hamilton, with the major differences being a) the use of psychologists rather than nurses or social workers, b) the absence of a separate administrative structure, c) slightly less psychiatrist time each month and d) the absence of dedicated funding to support indirect care such as case discussions and reviews, team meetings, and meetings with community partners (see Table 1 ) The Oslo model, aligned closely with the national health policy objectives of increasing collaboration and providing more assessments and treatment within primary care ( 29 ), and was tested in a cluster-randomised controlled trial (CRCT) in GP practices in three boroughs in Eastern Oslo. In each borough, one GP practice was randomized to implement the model over 18 months, while a control GP practice continued with care as usual. The 18-month implementation phase was considered long enough, based on studies showing that high fidelity implementation of a new practice is usually achieved in 12 to 18 months ( 30 , 31 ). We have previously described the frequency and reasons for GP consultations for mental distress in the participating GP services ( 11 ), associations between somatic symptoms and mental distress ( 8 ), GPs’ identification of mental distress ( 7 ), and characteristics of GP patients receiving treatment in the specialist mental health services ( 32 ). Based on the CRCT results, we have reported improvements in GPs' ability to detect mental disorders in young people ( 33 ), and an increase in sick leave and in a decrease in work assessment allowance ( 34 ). A qualitative sub-study showed that both patients and service providers felt that the collaboration it improved the health care ( 35 ). Aims The objectives of this paper are to evaluate (a) the adaptation of the HFHT model to the Norwegian context, (b) its implementation with a particular focus on challenges, and (c) sustainability of the model. Methods Design and framework As an overarching framework to address our stated aims, we used the UK MRC guidance of complex intervention, described in detail below ( 20 , 36 ). Within that framework we conducted a four stage qualitative analyses of available project documents related to the planning, preparation, implementation, challenges, and sustainability of the model to evaluate the process and present possible adjustments. See Fig. 1 for a timeline of the whole process. Insert Fig. 1 here Material and analysis Table 2 gives an overview of the documents used in the process evaluation. These include minutes from meetings during planning and implementation of the adapted collaborative care model, drafts of the proposed model discussed with and agreed upon by the participating services at before the start of the implementation, summaries from workshops held at the end of the 18 months implementation phase, and minutes and notes from the research group’s planning phase. The documents were all clearly identified as to their dates, origin and original purposes. Table 2 Documents used as material in the evaluation • Minutes and working documents from the research group’ planning and preparation of the 18 months cluster-randomised controlled trial of implementation of a collaborative care model. • The draft of the proposed adapted collaborative care model presented in recruiting participating services. • Information on the Hamilton Family Health Team model and notes from a three-days study visit to the HFHT in Hamilton by 14 persons from the participating services and the research group. • The agenda, the suggested adapted collaborative care model, list of issues needing clarifications, and minutes from the meeting where the participating services decided to implement the model. • Minutes from 17 monthly project meetings of the psychologists and psychiatrist in the collaborative care teams, managers at the CMHC and the principal investigator during the implementation phase. • Minutes from meetings of the working groups in each borough, that included the collaborative care team at the GP practice and selected managers from borough services. • Minutes from joint semi-annual meetings for all participating services. These focused on practical aspects of the implementation of the collaboration. • Summaries of the two half-day evaluation workshops for all participating services after the end of the 18-month implementation period, including presentations and group discussions. Insert Table 2 here The analysis of the documents took place in three stages, utilising different methods. The first stage of analyses included an inductive thematic analysis ( 37 ) to identify themes related to model adaptation; implementation and sustainability from the documents. The content of all documents was summarised to provide an overall impression of their content. Initial thoughts were noted. Themes were then generated, based on a line-by-line coding of all material. This was conducted by an experienced qualitative researcher, independent of the adaptation and implementation stages (JR). The themes were then refined through detailed discussed among with the authors (TR, AH) who had taken an active part throughout the process, This iterative process was also informed by the literature on collaborative care models and complex interventions. Themes from the planning and the implementation periods were kept separate. There was consistency in the themes emerging within each period and the resulting themes, and all themes were checked against the material to see if they reflected its content and were then incorporated into next analytical stages. The second stage of the analysis drew upon themes from the planning stages and utilised elements from the UK MRC framework for process evaluation of complex interventions to identify the “theory of change” of the adapted model ( 20 ) from the themes in stage one (see Fig. 2 ),. We also incorporated practical recommendations from the UK MRC framework to enhance the structure and content of our process evaluation ( 36 ). This included clarifying the competence and roles of the evaluators, the complex intervention (including theory of change), and the analyses and reporting the process evaluation ( 36 ). The third stage of the analysis used the Consolidated Framework for Implementation Research (CFIR) ( 38 ) to identify (based on themes related to implementation from stage one), and categorise potential challenges for implementation of the collaborative care model.. CFIR provides a pragmatic structure of five domains of factors: characteristics of the intervention (the collaborative care model), outer settings (e.g., national health politics), inner settings (e.g., participating services), the process, and characteristics of individuals. CFIR has also been used in research on sustainability ( 39 ) and was used to structure our Discussion section below. Results Adaption of the collaborative care model Planning and recruitment The project lead, a psychiatrist with extensive experience in working collaboratively with GPs ( 40 ), conceived the project after a visit to the Hamilton FHT in 2012. The HFHT model had been developed in a country with a similar health care system to Norway’s and offered a promising approach to collaboration between GPs, other community primary care providers and specialised mental health services, in line with national health policies in Norway ( 29 ). It was also feasible for the assessment and treatment of a broad group of GP patients. A multidisciplinary research group was established, including family physicians, psychiatrists, a sociologist, a psychologist, and a health economist, in addition to a user representative. Between them, the team had extensive experience in clinical work at primary and specialist levels, in quantitative and qualitative research methods, and in evaluating health services. This group planned and prepared the project, supported the implementation, and evaluated the process and the outcome of the CRCT. Local leadership within each borough, the director of specialised mental health services at Akershus University Hospital, and the CMHC manager also agreed to join the project. Managers of other primary care services in each borough were also interested in participation, but uncertain as to how much their services could be involved in the project. The research group designed the preliminary adapted collaborative care model and the CRCT to test it and obtained approvals from the regional and national research ethics committees and the hospital’s data protection officer. Recruitment of GP practices began in 2015, and when two GP practices had been recruited in each borough, they were randomised to participate in either collaborative care (intervention group) or to continue with care as usual (control group). The CMHC manager assigned three clinical psychologist specialists to each work half-time in a GP practice. Additionally, a psychiatrist, who was also part of the research team, was assigned to work one to two hours per week in each GP practice. This decision to use experienced clinical psychologists instead of mental health nurses or social workers was based upon previous positive experiences with collaborating psychologists and was supported by the Norwegian GP association. Preparation In September 2015, 11 people from the participating services (GPs, primary care managers and health workers, CMHC managers, psychiatrist, psychologists, child-adolescent psychiatrist) and three from the research group (GPs, psychiatrist) participated in a study visit to the HFHT in Hamilton. This three-day visit included workshops and small group visits to GP practices to gain insights into the organisation of the HFHT model, local staffing, practices, and experiences. In October 2015, a joint meeting of the participating services reviewed the proposed adapted collaborative care model, as well as a list of issues that needed to be clarified. The goal and aim of the project and the adapted collaborative model were defined and agreed upon as “The goal is to strengthen the health services provided by GPs in the field of mental health” and “The aim is to achieve better treatment, increased treatment satisfaction among both patients and service providers, and to find a model that is useful and sustainable over time.” These are included in the description of the adapted collaborative care model in Table 1 . GPs could initiate collaborative care for any of their patients and were not focused on or limited to any specific patient groups or treatments. The participating services agreed to initiate the collaborative care project, set to be operational for 18 months starting in early 2016. They also wanted the CMHC to manage the project. It was anticipated that national health authorities would support reimbursement for the collaborative activities in the project, which could potentially demonstrate the advantages of the national health policies focused on enhancing collaboration among health services and treatments provided by GPs and primary care. At the conclusion of the 18-month trial period, the participating services would determine whether and how the collaborative care model should continue. Several practical issues were clarified at this stage, including staffing, office space for the mental health specialists from the CMHC, the organisation of the collaboration, access to electronic patient records, and applying to the national health authorities regarding reimbursement for collaborative activities. It was agreed that a joint project group led by the CMHC and with members of the participating services in each of the three boroughs would further refine the model and determine how it could best be introduced in the practices. This work took three months, and the final adapted model is described below and in Table 1 . The adapted collaborative care model The adapted model consisted of two major components. The core component was a collaborative team co-located at each GP practice and consisting of the GPs and a half-time psychologist and a visiting psychiatrist (for two hours a week) from the CMHC. Office space was provided on-site, and the GPs and mental health specialists could easily contact each other to discuss a specific patient, a clinical issue, medications or a referral to another service. The mental health specialists provided assessments and short-term therapies for patients that the GPs referred to them, and the GP occasionally sat in on a consultation. Both GPs and mental health specialists had access to the patients’ electronic patient records and wrote their notes and summaries of assessments and treatments in the same electronic record. The extension component included the involvement of and collaboration with additional professionals from the borough’s other primary care, including addiction services and specialised mental health services, meeting regularly or on an ad hoc basis to discuss specific patients or situations. This extension of the collaborative care team allowed for the flexible utilisation of expertise from a wider range of services. Theory of change for the model as a complex intervention Recognising collaborative care as a complex intervention, the assumed mechanism or theory of change for the model would be that close interaction between co-located service providers with different expertise would facilitate establishing and utilising relationships, learning from each other while working together, and providing more comprehensive and earlier assessments and treatments for patients with developing mental health problems. For GPs, this would include learning to better detect and manage mental health problems. See Fig. 2 . The model did not include formal training in new competencies but assumed that participating GPs and mental health professionals would learn from each other as the project progressed. The implementation of the adapted collaborative care model focused on the process of collaboration and integrating mental health professionals in primary care, rather than on specific treatments to be employed. ( 21 , 41 ). Insert Fig. 2 here Implementation and experiences of the collaborative care model The collaborative care teams were established during the winter of 2016 and were operational for 18 months from March/April 2016 to October 2017. Implementation of the collaborative care model The collaboration activities of the team to implement the core component were as follows. The GPs initiated ad hoc discussions on patients or clinical issues, joint meetings with patients, and referred patients to the psychologist for assessment or therapy by reserving time in the psychologist’s schedule. The GPs demonstrated a keen interest in evaluating and treating patients with mental health challenges, although there was some variation in this interest among the different GPs. The therapeutic work of the psychologists was similar across the GP practices, providing short-term therapy much like in the CMHC outpatient clinic. On average the psychologists saw five patients per day, with a range from three to eight. Some patients referred by the GPs to the psychologists for therapy were deemed too ill for short-term therapy and they recommended a referral to the CMHC instead. Situations like these increased the GPs’ knowledge and experience in determining whom and where to refer and what information to include in referrals. All three psychologists experienced fluctuations in the collaboration over time, with some initial challenges and frustrations while introducing the model, followed by a period of successful collaboration. Two positive turning points were identified - one when the psychologists began reporting more positively about collaboration and workload, feeling integrated into the collaborative care team rather than being viewed as external professionals; and a second when the GPs stopped expressing concerns about the uncertainty regarding reimbursements for collaboration activities (see below). Challenges could arise, however, when GP substitutes replaced the GPs in the practices during summer holidays. One psychologist also found on return from a one-month leave that the GPs were reluctant to attend collaborative care team meetings and were referring an excessive number of patients to be seen instead. In the beginning the psychiatrist was assigned two hours a week at each of the three GP practices, but over time this was adjusted to respond to specific needs, spending less time in a practice with lower needs and additional time during a psychologist’s leave in another practice. The psychiatrist primarily assisted the GPs with reviews of the use and adjustments of psychotropic medications in specific patients, including long-term injectables, seeing the person if further clarification was needed. This increased the GPs’ competence and comfort in prescribing these medications. The psychiatrist observed that the GPs increasingly became more aware of the need to review long term medications and detect and manage mental health issues that were concurrent with physical symptoms. The psychiatrist also responded to questions from the psychologists about medications, usually meeting the patient together. They also assisted the psychologists with more complex cases, sometimes assessing the patient in person (along with the psychologist) and sometimes just by providing advice regarding further treatment options or referral to the CMHC. In addition, the psychologists established contacts with the municipal primary care and substance abuse services in their boroughs, and the local Employment and Welfare Administration. In one borough, the psychologist spent half a day weekly with their primary mental health care service, meeting with and supervising personnel and seeing some patients. In the two other boroughs, the psychologist’s contact with primary care was as needed. However, few of the borough service providers participated in the joint semi-annual collaborative meetings to discuss their experiences and future directions for the collaboration, indicating a possible lack of engagement. Mental health specialists from CAMHS and the outpatient clinic for substance abuse in the specialised mental health services could also be included when needed. It was soon concluded, however, that this was not necessary, as the GPs had well-established collaboration with these services and could easily contact them when needed. Wider stakeholder involvement in the project was more limited than intended. A service user representative from the local group of the national user organisation Mental Health was recruited to one of the collaborative care teams. She was involved in team meetings regarding the collaboration but not clinical meetings about specific patients. In the two other GP practices, the project was unsuccessful in recruiting service user representatives to the teams, or in involving family caregivers in the planning or implementation. There were some differences in contexts and local adaptions of the collaborative care model across the three GP practices, designated as team A, B, and C. In Team A (with 4 GPs) initial reactions to the project were mixed. While the GPs became increasingly positive over time, some remained hesitant to participate in collaborative meetings and patient discussions. Each GP in Team A had separate funding, which might have contributed to difficulties in forming joint plans for the entire group. Collaboration with the borough services was most systematic in Team A, where the manager in the borough's primary mental health care team engaged several local services in a weekly half-day session with the psychologist for supervision and case reviews. Team B (with 3 GPs) was the most integrated team, holding monthly meetings and regularly engaging in productive dialogues and joint case discussions. The psychologist and psychiatrist found it easy to discuss patients with the GPs after consultations, and each GP often allocated time to discuss medication with the psychiatrist. The project was seen to enhance local collaboration across various services, service levels, and disciplines. Team C (with 4 GPs) felt they had less needs for collaboration with the borough primary care services. This may have been due to fewer socioeconomic problems in their part of the borough and because they treated many patients from outside the borough. Patients referred to the psychologist tended to have fewer complex issues compared to those in the other teams, with fewer referrals to the psychiatrist for medication reviews. The borough provided low threshold "rapid mental health care" services with psychologists, allowing the team’s psychologist to refer patients when pressed for time. Team meetings were less frequent in Team C. Experiences with the collaborative care model The GPs expressed satisfaction with the model and wanted to see it continue. They noted several benefits, including shorter waiting times for mental health care and greater accessibility when care was provided within their practices. Additionally, they experienced personal gains, such as heightened awareness of mental health issues and increased confidence in assessing and managing mental health problems. They also gained a better understanding of the services offered by the CMHC and the borough, feeling that the personal relationships developed with personnel from other services facilitated easier collaboration. The psychologists and psychiatrist also reported positive experiences with the model. They gained insights into GP work, the comorbidity of mental and physical illnesses, the treatment of physical health issues, and the available borough services. Compared to their experiences in the outpatient clinic, they saw that clinical improvements could occur more rapidly, as they were able to engage with patients at an earlier stage when problems might be less severe. Healthcare professionals in the borough's services had diverse experiences with the collaborative care model. Some had participated in the visit to Hamilton and were familiar with the model, while others needed more time to understand how borough services could be involved in collaborative care. Variations in population needs and the organisation of borough services also impacted their participation. Overall, the participating borough services appreciated having a common meeting point to familiarise themselves with each other, understand one another's practices, discuss issues, and learn about other services. They also recognised that greater utilisation could have been made of borough services such as the "rapid back to work" mental health program, the local Employment and Welfare Administration, and substance abuse primary care if they had been more involved and found ways to contribute their specific expertise. Challenges in the implementation of collaborative care Three significant barriers to implementation were identified: the workload of the psychologists, the GPs’ lack of time to attend meetings, and uncertainty about reimbursement for collaborative activities at GP practices. Initially, the psychologists' workload was overwhelming, as they were assigned too many patients per day. As their schedules began to fill weeks in advance, their ability to schedule new appointments for patients needing more therapy became limited. This issue was resolved by allowing psychologists to take more control over their schedules, restrict the number of patients seen per day, and use a scheduling block function to reserve slots for future therapy sessions. These adjustments were made after discussions with the GPs at their practices. GPs' lack of time for attending collaboration meetings was a recurring issue, as their increasing administrative workload limited the available time for meetings. Financial challenges emerged early in the planning phase, as implementing the model without additional funding presented significant difficulties for the participating services. GP practices incurred various expenses, including office space, access to electronic patient records, and secretarial support, in addition to the time dedicated to collaboration. For the CMHC, assigning two full-time staff equivalents to collaborate with the three GP practices reduced the number of consultations that could be provided at the outpatient clinic, thus increasing the workload for other clinical staff and potentially impacting annual funding. It was unclear from the outset whether GPs could be reimbursed for patient consultations conducted by the psychologist or for time spent on collaborative activities, and patients could not be charged fees for consultations not eligible for reimbursement. Similarly, the CMHC could not charge fees or obtain reimbursement for patients seen by a psychologist or psychiatrist at a GP's practice. It was anticipated that national health authorities would recognise the CRCT’s value in relation to national health policy and offer flexibility regarding reimbursement during the 18-month implementation phase. Despite multiple requests over time to increasing higher levels of national health authorities, no special reimbursement arrangements were made. Consequently, the collaboration had to proceed without reimbursement for collaborative activities, causing significant frustration for participants and prompting discussions about the implications for long-term sustainability. Conclusion regarding sustainability of the model Ultimately, despite the successful implementation and positive experiences of the collaborative care model, the lack of reimbursement for collaborative activities led both the GP practices and the CMHC to conclude that the model could not be sustained beyond the 18-month implementation phase, without additional funding. The financial losses made it impossible for the GP practices to continue, and the CMHC lacked the economic and human resources to maintain the collaboration model or expand it to additional GP practices. The borough services had not committed any specific resources and were not involved in the decision to discontinue the collaborative care model. Discussion The implementation of the model Characteristics of the complex intervention The core component of the adapted model was successfully implemented and perceived as beneficial. GPs and mental health specialists effectively utilised their complementary knowledge and skills to meet the diverse needs of different patients, while simultaneously enhancing their own competencies. All three participating teams successfully integrated the primary elements of the model. The variations observed across the three practices showcased the model's flexibility, allowing it to be tailored to meet specific local contexts and needs ( 42 ). A qualitative study exploring the experiences of GPs and mental health specialists with the model identified key factors contributing to its success: the co-location and the mental health specialist acting as a front-line contact ( 35 ). This supports the assumption that the mechanism in this complex intervention was the close collaboration between co-located GPs and mental health specialists with complementary expertise. As in Hamilton, the collaboration addressed a wide range of problems, unlike many other collaborative care models that focus on a specific diagnostic group or treatment ( 43 – 45 ). In the current study, the psychologist also offered ad hoc meetings with the GPs, assessments, and short-term therapy options. Unlike in Hamilton, the current project implemented the adapted model without establishing a new administrative organisation. This facilitated the initiation of implementation without requiring organisational changes, which would have been difficult to achieve within the existing structure of Norwegian health services. The extension component of the model was also flexible, depending upon how borough services were organised and what each could contribute to collaborative care. Unlike the core component, however, which involved only a few individuals at each practice, implementing the extension component proved more challenging. It necessitated the involvement of a wide range of services across various locations, with multiple teams and professionals who also needed to coordinate with other GP practices within the borough. Outer setting and inner setting factors affecting the collaboration The major barrier to the sustainability of the collaborative care model in the Norwegian context was the lack of financial reimbursement for collaborative activities between primary and specialised health care, reflecting the separate funding systems for these two healthcare sectors. Although recent national health policies aim to reduce fragmentation, boost collaboration, and enhance the roles of GPs and other primary care providers, the financial system currently undermines these objectives, discouraging collaboration in GP practices ( 29 ). To resolve this, health service funding needs to better align with national health policy goals. Our previous paper on the model’s effect on sick leave and work assessment allowance indicates that the model may offer substantial economic benefits for the society ( 34 ). While days of patients’ (short-term) sick leave increased by 4% in collaborative care practices compared to control practices, subsequent days receiving longer time work assessment allowance decreased by 8%, and these changes came from the patients with mental health problems. This indicates that early identification and treatment (including sick leave) of mental health problems leads to a better long-term prognosis with a reduction in long term work assessment allowance, and probably in disability pension. Based on the HFHT model, we found that having a half-time psychologist and a visiting psychiatrist for two hours weekly at each GP practice created a viable collaborative care team. This arrangement matched the resources available from the CMHC and the support the GP practices could offer regarding office space and logistics. With each practice having 3–4 GPs, the consistent staffing of mental health specialists across the three practices was effective and remained unchanged throughout the project. Additionally, the weekly half-day commitment from the psychologist for collaboration and clinical supervision with the borough proved successful. The implementation process Some aspects of the implementation process could have been improved. Service users, family caregivers, and borough service providers had limited involvement, leading to GPs and mental health specialists dominating planning and implementation. Engaging borough service managers more actively, perhaps through joint leadership, might have boosted participation. Training on collaboration principles and practices during the preparation phase might have strengthened involvement, though it would have required additional time for participating service providers. GPs and mental health specialists deemed such training unnecessary, as the model’s core component utilised their existing competencies to address issues as they arose. No external supervision was provided for the collaborative care teams, except for project meeting discussions at the CMHC involving psychologists and psychiatrists. Although the 18-month implementation period was sufficient to demonstrate the potential benefits of the collaborative care model, it was not long enough to develop and test adjustments that might have led to a more sustainable model, unlike the HFHT model that evolved over many years ( 23 , 24 ). In retrospect, the issue of financing for collaborative activities should have been clarified before the start of the implementation. Without this, the project became more of a pilot aimed at testing and promoting the model, rather than a fully sustainable, scalable exercise. Involving all stakeholders over a longer period before start might have identified further adjustments that needed to be made to facilitate scalability. On the other hand, knowing earlier that the anticipated reimbursements would not be provided, might have led to the cancellation of the implementation, thereby forfeiting the opportunity to understand how the model could function in practice. No systematic process evaluation plan was drafted during the planning phase, as the focus at that time was on testing the adapted collaborative care model in a CRCT. Collecting data on informal aspects, like ad hoc meetings, would also have been difficult. If resources had permitted, an external expert evaluation might have added credibility. Nevertheless, when conducting the evaluation, the research team was able to build on their knowledge of the implementation process across all phases, drawing upon their expertise in relevant clinical work, collaboration, and health services research. While the research group may have been biased when using their expertise in discussing factors affecting the implementation of the model, the implementation and the experiences of the collaborative care were documented in minutes and summaries from meetings and workshops. In addition to the two workshops with the participating services after the 18 months, the research group presented the results from the published papers and this evaluation during visits to the GP practices, where the participating GPs reviewed, recognised and confirmed the findings. Adjustments to make the model sustainable Suggested adjustments of the model under current financial circumstances During workshops held at the end of the project, the participants and the research group discussed several potential adjustments to make the model more sustainable under current circumstances. One suggestion was to reduce the time that the mental health specialists spend in GP practices, as had been the case with a similar model employed by the CMHC in previous years. This approach also aligns with the model practised by the project lead (a psychiatrist), who had previously visited 20 GPs and other primary care services across six municipalities in a CMHC catchment area, dedicating one full day every week to this over 15 years ( 40 ). Reducing the psychologists’ time providing short-term therapies would also enhance the model's viability. Video meetings and other electronic communication methods, which gained prominence during the Covid-19 pandemic, could also be utilised ( 46 ). In addition, training GPs in specific skills, such as cognitive-behavioural therapy, might also be considered as an adjustment to the model. CBT is increasingly used in many GP practices in Norway and other countries ( 47 , 48 ). Collaboration and communication could also be enhanced by holding regular clinical meetings between GPs, primary care providers, and mental health specialists to discuss specific cases and support the service providers involved. These meetings could improve continuity of care, strengthen relationships between GPs, primary care, and specialised mental health services, and increase their skills. Larger, less frequent meetings involving all service providers could focus on broader system issues, such as service provision, capacities, expectations, and fostering collaboration procedures. Ways of improving patient transfers between services could include preparing the patient appropriately, sending early referrals, sharing information about previous treatments, suggesting further treatment, and organising joint transfer meetings with the patient and involved services. Mutual understanding and collaboration among healthcare workers could also be strengthened through internships or mutual visiting arrangements between services and joint educational events. Policy changes needed for more extensive collaboration For collaboration to succeed, it is crucial for the government and national health authorities to recognise collaborative care with GPs as a mandatory responsibility of specialists working within specialised mental health services. This recognition should be supported by financial incentives. For instance, GP practices could be reimbursed for treatment sessions involving mental health specialists working alongside GPs, as well as for internal interprofessional meetings to discuss cases, similar to how meetings with other service providers are reimbursed. Other countries provide examples of how collaborative care can be financed ( 49 ). Such measures would align with recommendations from the World Health Organisation and the experiences of many countries that have integrated mental health care within primary care settings ( 50 ). In Norway, a government-appointed expert committee has recently provided advice on the thematic organisation of mental health services, including collaboration between GPs, primary health care, and specialised mental health care, referencing the results and experiences of our project ( 33 , 35 , 51 ). Enhancing collaboration between mental health and primary care services can also be facilitated by changes in organisational functioning, as highlighted in a recent joint position paper from the Canadian Psychiatric Association and the College of Family Physicians of Canada ( 25 , 29 ). Strengths and limitations One of the strengths of the process evaluation was the ability to compare the adapted collaborative care model with a well-established one, which has evolved and been sustained over three decades. Reviewing written minutes and notes from the planning, preparation, and implementation phases provided valuable documentation of the steps taken. The results from the process evaluation and the experiences gained from the model will be useful for interpreting the primary outcomes of the CRCT. However, a significant limitation was the absence of a systematic plan for the process evaluation during the planning of the CRCT. This oversight resulted in limited data collection on various aspects of the implementation, such as the involvement of borough services and ad hoc meetings between GPs and mental health specialists. Conclusion and implications The core component of a collaborative care model between co-located GPs and mental health specialists was successfully implemented and was seen by the participating service providers as an improvement in the delivery of health care. However, it proved unsustainable due to the lack of reimbursement for collaborative activities and associated costs. The extension component, which involved collaborating with other borough services, was only partially implemented, more so in one borough and less in two, possibly because they weren’t more fully involved at the start of the project. The results indicate that the sustainability of such a model relies on reimbursing GPs for collaborative activities and formally recognising that closer working relationships with GP practices should be integral to specialised mental health services. It is crucial to tailor the range of collaborative activities to available resources, especially given the limited capacity to co-locate mental health specialists within GP practices. Achieving more extensive collaboration may require organisational and practice changes at national, regional, and local levels. Abbreviations CAMHS Child and Adolescent Mental Health Services CBT Cognitive Behavioural Therapy CMHC Community Mental Health Centre CRCT Cluster-randomised controlled trial GP General Practitioner HFHT Hamilton Family Health Team ICPC International Classification of Primary Care IT Information technology UK MRC UK Medical Research Council Declarations Ethical approvals The CRCT received the necessary approvals from The Regional Committee for Medical and Health Research Ethics South-East (REC, reg. no. 2014/435), The National Committee for Medical and Health Research Ethics (NEM, reg. no. 2014/160), and the Data Protection Officer at Akershus University Hospital (reg. no. 2013-138). Written informed consent to participate in the CRCT was obtained for patients completing a questionnaire at GP practices during a two-weeks data collection, and REC and NEM granted exemption from confidentiality to extraction of some specified structured data from the electronic patient records in GP practices for the previous 12 months. The current study did not use any patient data or any personal information on health personnel. The four mental health specialists that may be identified by someone knowing the study well, have given consent to publishing the study. Such studies without personal information on patients or others do not need ethical approval from REC and NEM according to Norwegian law. The study adhered to the Declaration of Helsinki. Clinical trial number Not applicable Consent for publication Not applicable. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The study was partially funded by the Regional Health Authority South-East (project no. 2013132). The work of the authors was done as a part of their job at their affiliations. Authors’ contributions TR conceived the study, was principal investigator, planned the paper, and drafted the manuscript. AH contributed to planning the study, was consultant psychiatrist in the three collaborative teams, and participated in the project meetings during the implementation. JR, ORH and MPD contributed to planning the study. All authors (including KHB, MB, OGT, NK) contributed to writing and revisions of the manuscript and read and approved the final manuscript for submission. Acknowledgements We are grateful to the health workers in the participating services for their efforts in implementing the adapted collaborative care model and for their input to the process evaluation by communicating their experiences with the model and suggesting adjustments to make it more sustainable. References Lampe L, Shadbolt N, Starcevic V, Boyce P, Brakoulias V, Hitching R, et al. Diagnostic processes in mental health: GPs and psychiatrists reading from the same book but on a different page. Australas Psychiatry. 2012;20(5):374-8. Klimas J, Neary A, McNicholas C, Meagher D, Cullen W. The prevalence of common mental and substance use disorders in general practice: a literature review and discussion paper. Mental Health and Substance Use. 2014;7(4):497-508. Sundquist J, Ohlsson H, Sundquist K, Kendler KS. Common adult psychiatric disorders in Swedish primary care where most mental health patients are treated. BMC Psychiatry. 2017;17(1):235. 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Detecting young people with mental disorders: a cluster-randomised trial of multidisciplinary health teams at the GP office. BMJ Open. 2021;11(12):e050036. Kann IC, Dahl MP, Ruud T. New collaborative care model for patients with mental disorders: Is sick leave or work assessment allowance money affected? [Ny samhandlingsmodell for pasienter med psykiske lidelser: Påvirkes sykefravær eller arbeidsavklaringspenger?]. Arbeid og velferd. 2019(2):27-41. Rugkasa J, Tveit OG, Berteig J, Hussain A, Ruud T. Collaborative care for mental health: a qualitative study of the experiences of patients and health professionals. BMC Health Serv Res. 2020;20(1):844. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101. 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Oslo: National Centre for Knowledge in Health Services; 2008. McHugh SM, Riordan F, Curran GM, Lewis CC, Wolfenden L, Presseau J, et al. Conceptual tensions and practical trade-offs in tailoring implementation interventions. Front Health Serv. 2022;2:974095. Carron T, Rawlinson C, Arditi C, Cohidon C, Hong QN, Pluye P, et al. An Overview of Reviews on Interprofessional Collaboration in Primary Care: Effectiveness. Int J Integr Care. 2021;21(2):31. Miller CJ, Grogan-Kaylor A, Perron BE, Kilbourne AM, Woltmann E, Bauer MS. Collaborative chronic care models for mental health conditions: cumulative meta-analysis and metaregression to guide future research and implementation. Med Care. 2013;51(10):922-30. Woltmann E, Grogan-Kaylor A, Perron B, Georges H, Kilbourne AM, Bauer MS. Comparative effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings: Systematic Review and Meta-Analysis. Am J Psychiatry. 2012;169(8):790-804. Zanaboni P, Fagerlund AJ. Patients' use and experiences with e-consultation and other digital health services with their general practitioner in Norway: results from an online survey. BMJ Open. 2020;10(6):e034773. Haavet OR, Myhrer KS, Kates N, Mdala I, Aschim B, Lundevall S, et al. Impact of a cognitive behavioural therapy training program on family physician practices Cross-sectional study in Norway. Canadian Family Physician. 2023;69:784-91. Truelove S, Ng V, Kates N, Alloo J, Sunderji N, Patriquin MJ. Collaborative mental health care. Engaging health systems to support a team-based approach. Canadian family physician. 2023;69(2):81-3. Wolk CB, Alter CL, Kishton R, J. R, Atlas JA, Press MJ, et al. Improving Payment for Collaborative Mental Health Care in Primary Care. Med Care. 2021;59:324-6. WHO. Mental health in primary care: Illusion or inclusion? Geneva: World Health Organization 2018. Helse-_og_omsorgsdepartementet. Forenkle og forbedre. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6030253","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":440738845,"identity":"23d1b64b-c76f-4c0f-a5a9-ae402cdfadcf","order_by":0,"name":"Torleif 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model\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6030253/v1/ccd21842632f2a1d875f7f6e.jpeg"},{"id":90827836,"identity":"e4ec156b-5575-4539-a400-c04bd74b0560","added_by":"auto","created_at":"2025-09-08 16:01:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2044181,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6030253/v1/c9b7df72-c87c-4b38-a6f6-7a5510b7b521.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A collaborative primary and mental health care model with psychologist and psychiatrist working in GP practices: Process evaluation of the implementation, challenges, and sustainability","fulltext":[{"header":"Background","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eThe needs for collaborative mental health care\u003c/h2\u003e \u003cdiv id=\"Sec3\" class=\"Section3\"\u003e \u003ch2\u003eThe role of general practitioner (family physician) in delivering mental health care\u003c/h2\u003e \u003cp\u003eGeneral practitioners (GP) plays a key role in delivering mental health care in any health care system (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), seeing a larger proportion of patients with mental illness than specialised mental health services (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Early intervention, and continuity in the GP-patient relationship are significantly associated with lower use of out-of-hours services, fewer acute hospital admissions, lower mortality rates, and reduced pressure on specialized mental health services (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, for GPs who have busy schedules, usually seeing twenty or more patients per day, while also carrying financial responsibility for employees working in their practice (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), identifying mental disorders (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) can be challenging, especially when there are concurrent or related physical issues (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Norway, as elsewhere, there is acceptance of the value of better collaboration between GPs and specialised mental health services (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e–\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). GPs refer patients needing specialist assessment or treatment and will then collaborate in providing treatment, but often face problems in accessing these services. Studies have demonstrated, however, that GPs who have better access to mental health specialists demonstrate improved skills, knowledge, and confidence when treating patients with mental disorders (\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e–\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Improving collaboration with patients and their families can also ease the problems posed by fragmented health services (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eModels of collaborative care\u003c/h3\u003e\n\u003cp\u003eOne solution to these challenges is to integrate mental health professionals within primary care settings (collaborative care). Collaborative care is used to describe “the process where primary care and mental health providers share resources, expertise, knowledge, and decision-making to ensure that primary care populations receive person-centred, effective, and cost-effective care in the most convenient location and in the most timely and well-coordinated manner possible.” (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). It usually involves complex interventions (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), with several interacting components, such as multiple services or teams, various professions, individuals with different competencies, and the completion of multiple tasks related to assessment and treatment. Evidence-informed principles for designing collaborative care include the co-location or close physical proximity of collaborators collaborative relationships, shared goals and a structured organizational framework for the collaboration (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e–\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough various collaborative care approaches have been described and evaluated, systematic knowledge about the results and experiences of collaboration in Norway is limited. But one successful model based on these principles is the Hamilton Family Health Team’s (HFHTs) model of collaborative care, in Ontario, Canada, which has now been in place for 30 years (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eThe Hamilton Family Health Team (HFHT) Model\u003c/h3\u003e\n\u003cp\u003eThe Hamilton Family Health Team now includes 180 physicians in 83 practices in a city of 500,000 in Southern Ontario, Canada. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Each practice has developed a multidisciplinary team that is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Each team includes one or more family physicians, nurses, mental health counsellors, a visiting consulting psychiatrist, and other part-time health professionals (pharmacist, nutritionist, physiotherapist, occupational therapist) who may also play a role in providing mental health care. Team members are co-located in the Family Physicians’ offices and provide assessments, treatment and therapy, health teaching, relapse prevention and linkage with community services, for people presenting with a comprehensive range of problems. The goal is to provide accessible and comprehensive health care close to where the patient lives, with minimal fragmentation of care. The Hamilton FHT - and other collaboration approaches based on this model – has demonstrated many benefits for patients and service providers (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). We selected this model to see if it could be adapted to and implemented in the Norwegian context.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe adapted Norwegian collaborative care model compared to the model of Hamilton Family Health Teams – Mental Health Program (MHC = mental health counsellor, CMHC = community mental health centre)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComponent\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHamilton Family Health Teams – Mental Health Program (HFHT)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAgreed adapted collaborative care model for implementation in three Norwegian GP practices\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAims\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImprove collaboration between local mental health practitioners and primary care services and improve Family Physicians competencies and skills.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrengthen the GP practice’s health care for patients with mental and comorbid disorders, study the benefits of collaborative care teams, and adjust the model based on the results of the project.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganization\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHFHT is a separate organization with a pool of different professionals who are working in or visiting FP practices.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo new organization established. The collaborating services decide how much resources they use in the collaboration.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancing of care and collaboration\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHFHT has public financing from the Ontario Ministry of Health. FPs have public funding on a capitation basis (monthly sum per patient). For both FPs and HFHT this funding supports collaboration.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo extra or external funding for the collaborating services, they used their own resources. Psychologists and psychiatrist paid by CMHC. GP practice cover costs for office space and access to patient electronic records. Applications to the national health authorities for financial reimbursements during the project.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgreement\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgreement between GP practice and HFHT is integrated within a common governance framework with Ontario Ministry of Health.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe participating services (GPs, CMHC, borough services) agreed to participate in implementing the collaborative care model for an 18-months test, waiting to decide if it then would be prolonged.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCore component\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntegration of mental health counsellors and visiting psychiatrist in GP practices\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntegration of clinical psychologist and psychiatrist into GP practices. Co-location or close location.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical staffing per GP/practice\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1–6 GPs at each practice 0.25–0.30 mental health counsellor/GP\u003c/p\u003e \u003cp\u003e1 MHC per 7000 GP patients.\u003c/p\u003e \u003cp\u003eAccess to dietician, pharmacist, addiction specialists, child/adolescent specialists, others\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3–4 GPs at each practice (each with ca. 1000 patients)\u003c/p\u003e \u003cp\u003e0.13–0.17 clinical psychologist specialist per GP\u003c/p\u003e \u003cp\u003e0.05 psychiatrist per GP practice\u003c/p\u003e \u003cp\u003e1 psychologist specialist per 8000 GP patients.\u003c/p\u003e \u003cp\u003eAd hoc access to addiction specialists, child/adolescent specialists.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetence of the main mental health worker in the collaboration\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHC: Nurse or master-degree social worker with experience from working in the mental health services.\u003c/p\u003e \u003cp\u003eExperienced consultant psychiatrist.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical psychologist specialists and consultant psychiatrist with extensive experience from mental health services.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIT/patient records\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGP practice electronic patient records\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGP practice electronic patient records\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollaboration within GP practice\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReferrals from GP to MHC/psychiatrist,\u003c/p\u003e \u003cp\u003ead hoc discussions, joint sessions. MHC provide crisis interventions, short-term treatments, family support, groups. Psychiatrist provides medication review and guidance, and consultation on complex patients.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReferrals from GP to psychologist/psychiatrist,\u003c/p\u003e \u003cp\u003ead hoc discussions, joint sessions. Psychologist provides assessments and short-term therapies.\u003c/p\u003e \u003cp\u003ePsychiatrist provides medication review and guidance, and consultation on complex patients.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollaboration with other primary care or other specialised mental health care\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMHC informs and link patients to other community resources, help with referrals to mental health services\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContact with other primary care providers in meetings or when requested. Psychologist linking patients to other community resources, help with referrals to other specialised mental health services\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCare coordination\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBy GP or mental health counsellor\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGP is care-coordinator for the patients\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining and supervision\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraining by HFHT when starting to work in HFHT. Regular clinical and administrative meetings in HFHT.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAcquired clinical and collaborative competence. Information on the HFHT model from visiting and literature. Mutual discussions. No external supervision.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdministration\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral staff and location of HFHT\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMeetings in GP practice and the CMHC project group\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003eInsert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here\u003c/p\u003e\n\u003ch3\u003eThe Norwegian health services\u003c/h3\u003e\n\u003cp\u003eHealth care in Norway is publicly funded, other than small co-payments for services provided in primary care (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Municipalities are responsible for organizing and providing primary health services, which includes GP services, home nursing, care for the elderly, rehabilitation, and primary mental health services. Specialised mental health services, along with general hospitals, are funded through health trusts administered through four regional health authorities. This split in funding increases the need for better collaboration between the mental health and primary care sectors. Community mental health centres (CMHCs) are mandated to collaborate with GPs and be available for consultation, but there is limited knowledge about the effects of these collaborations or the models that are employed.\u003c/p\u003e \u003cp\u003eNorway’s patient-list system, managed by the Norwegian Health Economics Administration, gives all Norwegians the right to a permanent GP, and 96% of the population were registered with one in 2016. The average GP looks after 1000–1500 people, with approximately 1 family physician (full or part-time) per 1000 population. The majority of GPs in Norway are self-employed with nearly one third of their income coming from the local municipality based on the number of patients on their list, two third coming from the Norwegian Labour and Welfare Administration as fee-for-services for patient contacts reported with codes from the International Classification of Primary Care version 2 (ICPC-2), and the remainder from a modest co-payment for each consultation that is paid by the patient. A small but increasing number of GPs in Norway are now fully salaried.\u003c/p\u003e\n\u003ch3\u003eThe current study\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eThe three Oslo boroughs (Alna, Grorud, Stovner) where this study was conducted, had a total population of 108 000 and were served by 85 GPs in 20 practices. Each borough had a range of primary care services, including general nurses, mental health workers, and local substance abuse care. Care is provided in the patient’s home when necessary, and the city of Oslo also has clinics in Emergency Rooms operating 24/7. Social services, employment services and social security are provided by the government’s New Employment and Welfare Administration agency. The specialised mental health services for the boroughs are provided by a CMHC for adults, child and adolescent mental health services (CAMHS) and other departments of the Mental Health Services at the Akershus University Hospital. The CMHC has outpatient clinics, mobile teams and inpatient units.\u003c/p\u003e \u003cp\u003eIn the three boroughs, the usual collaboration between GPs and specialised mental health services involved referring patients to each other and providing services in separate locations, rarely meeting with each other or seeing a patient together. A national survey conducted in 2018 revealed that GPs felt that collaboration with CMHCs had significantly decreased since 2014, after two decades of consistent improvement, and that the level of collaboration in these three boroughs was below the national average (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThe cluster-randomised controlled trial of the adapted collaborative care model\u003c/h3\u003e\n\u003cp\u003eThe adapted Oslo model (described in more detail under Results) was similar to that employed in Hamilton, with the major differences being a) the use of psychologists rather than nurses or social workers, b) the absence of a separate administrative structure, c) slightly less psychiatrist time each month and d) the absence of dedicated funding to support indirect care such as case discussions and reviews, team meetings, and meetings with community partners (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe Oslo model, aligned closely with the national health policy objectives of increasing collaboration and providing more assessments and treatment within primary care (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), and was tested in a cluster-randomised controlled trial (CRCT) in GP practices in three boroughs in Eastern Oslo. In each borough, one GP practice was randomized to implement the model over 18 months, while a control GP practice continued with care as usual. The 18-month implementation phase was considered long enough, based on studies showing that high fidelity implementation of a new practice is usually achieved in 12 to 18 months (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe have previously described the frequency and reasons for GP consultations for mental distress in the participating GP services (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), associations between somatic symptoms and mental distress (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), GPs’ identification of mental distress (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), and characteristics of GP patients receiving treatment in the specialist mental health services (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Based on the CRCT results, we have reported improvements in GPs' ability to detect mental disorders in young people (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), and an increase in sick leave and in a decrease in work assessment allowance (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). A qualitative sub-study showed that both patients and service providers felt that the collaboration it improved the health care (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eAims\u003c/h3\u003e\n\u003cp\u003eThe objectives of this paper are to evaluate (a) the adaptation of the HFHT model to the Norwegian context, (b) its implementation with a particular focus on challenges, and (c) sustainability of the model.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eDesign and framework\u003c/h2\u003e\u003cp\u003eAs an overarching framework to address our stated aims, we used the UK MRC guidance of complex intervention, described in detail below (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Within that framework we conducted a four stage qualitative analyses of available project documents related to the planning, preparation, implementation, challenges, and sustainability of the model to evaluate the process and present possible adjustments. See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for a timeline of the whole process.\u003c/p\u003e\u003cp\u003eInsert Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here\u003c/p\u003e\u003ch2\u003eMaterial and analysis\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e gives an overview of the documents used in the process evaluation. These include minutes from meetings during planning and implementation of the adapted collaborative care model, drafts of the proposed model discussed with and agreed upon by the participating services at before the start of the implementation, summaries from workshops held at the end of the 18 months implementation phase, and minutes and notes from the research group’s planning phase. The documents were all clearly identified as to their dates, origin and original purposes.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDocuments used as material in the evaluation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"1\"\u003e\u003c/colgroup\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e• Minutes and working documents from the research group’ planning and preparation of the 18 months cluster-randomised controlled trial of implementation of a collaborative care model.\u003c/p\u003e \u003cp\u003e• The draft of the proposed adapted collaborative care model presented in recruiting participating services.\u003c/p\u003e \u003cp\u003e• Information on the Hamilton Family Health Team model and notes from a three-days study visit to the HFHT in Hamilton by 14 persons from the participating services and the research group.\u003c/p\u003e \u003cp\u003e• The agenda, the suggested adapted collaborative care model, list of issues needing clarifications, and minutes from the meeting where the participating services decided to implement the model.\u003c/p\u003e \u003cp\u003e• Minutes from 17 monthly project meetings of the psychologists and psychiatrist in the collaborative care teams, managers at the CMHC and the principal investigator during the implementation phase.\u003c/p\u003e \u003cp\u003e• Minutes from meetings of the working groups in each borough, that included the collaborative care team at the GP practice and selected managers from borough services.\u003c/p\u003e \u003cp\u003e• Minutes from joint semi-annual meetings for all participating services. These focused on practical aspects of the implementation of the collaboration.\u003c/p\u003e \u003cp\u003e• Summaries of the two half-day evaluation workshops for all participating services after the end of the 18-month implementation period, including presentations and group discussions.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003eInsert Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here\u003c/p\u003e\u003cp\u003eThe analysis of the documents took place in three stages, utilising different methods. The first stage of analyses included an inductive thematic analysis (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) to identify themes related to model adaptation; implementation and sustainability from the documents. The content of all documents was summarised to provide an overall impression of their content. Initial thoughts were noted. Themes were then generated, based on a line-by-line coding of all material. This was conducted by an experienced qualitative researcher, independent of the adaptation and implementation stages (JR). The themes were then refined through detailed discussed among with the authors (TR, AH) who had taken an active part throughout the process, This iterative process was also informed by the literature on collaborative care models and complex interventions. Themes from the planning and the implementation periods were kept separate. There was consistency in the themes emerging within each period and the resulting themes, and all themes were checked against the material to see if they reflected its content and were then incorporated into next analytical stages.\u003c/p\u003e\u003cp\u003eThe second stage of the analysis drew upon themes from the planning stages and utilised elements from the UK MRC framework for process evaluation of complex interventions to identify the “theory of change” of the adapted model (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) from the themes in stage one (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e),. We also incorporated practical recommendations from the UK MRC framework to enhance the structure and content of our process evaluation (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). This included clarifying the competence and roles of the evaluators, the complex intervention (including theory of change), and the analyses and reporting the process evaluation (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe third stage of the analysis used the Consolidated Framework for Implementation Research (CFIR) (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) to identify (based on themes related to implementation from stage one), and categorise potential challenges for implementation of the collaborative care model.. CFIR provides a pragmatic structure of five domains of factors: characteristics of the intervention (the collaborative care model), outer settings (e.g., national health politics), inner settings (e.g., participating services), the process, and characteristics of individuals. CFIR has also been used in research on sustainability (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) and was used to structure our Discussion section below.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAdaption of the collaborative care model\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003ePlanning and recruitment\u003c/h2\u003e \u003cp\u003eThe project lead, a psychiatrist with extensive experience in working collaboratively with GPs (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), conceived the project after a visit to the Hamilton FHT in 2012. The HFHT model had been developed in a country with a similar health care system to Norway\u0026rsquo;s and offered a promising approach to collaboration between GPs, other community primary care providers and specialised mental health services, in line with national health policies in Norway (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). It was also feasible for the assessment and treatment of a broad group of GP patients.\u003c/p\u003e \u003cp\u003eA multidisciplinary research group was established, including family physicians, psychiatrists, a sociologist, a psychologist, and a health economist, in addition to a user representative. Between them, the team had extensive experience in clinical work at primary and specialist levels, in quantitative and qualitative research methods, and in evaluating health services. This group planned and prepared the project, supported the implementation, and evaluated the process and the outcome of the CRCT.\u003c/p\u003e \u003cp\u003eLocal leadership within each borough, the director of specialised mental health services at Akershus University Hospital, and the CMHC manager also agreed to join the project. Managers of other primary care services in each borough were also interested in participation, but uncertain as to how much their services could be involved in the project.\u003c/p\u003e \u003cp\u003eThe research group designed the preliminary adapted collaborative care model and the CRCT to test it and obtained approvals from the regional and national research ethics committees and the hospital\u0026rsquo;s data protection officer. Recruitment of GP practices began in 2015, and when two GP practices had been recruited in each borough, they were randomised to participate in either collaborative care (intervention group) or to continue with care as usual (control group).\u003c/p\u003e \u003cp\u003eThe CMHC manager assigned three clinical psychologist specialists to each work half-time in a GP practice. Additionally, a psychiatrist, who was also part of the research team, was assigned to work one to two hours per week in each GP practice. This decision to use experienced clinical psychologists instead of mental health nurses or social workers was based upon previous positive experiences with collaborating psychologists and was supported by the Norwegian GP association.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePreparation\u003c/h2\u003e \u003cp\u003eIn September 2015, 11 people from the participating services (GPs, primary care managers and health workers, CMHC managers, psychiatrist, psychologists, child-adolescent psychiatrist) and three from the research group (GPs, psychiatrist) participated in a study visit to the HFHT in Hamilton. This three-day visit included workshops and small group visits to GP practices to gain insights into the organisation of the HFHT model, local staffing, practices, and experiences.\u003c/p\u003e \u003cp\u003eIn October 2015, a joint meeting of the participating services reviewed the proposed adapted collaborative care model, as well as a list of issues that needed to be clarified. The goal and aim of the project and the adapted collaborative model were defined and agreed upon as \u0026ldquo;The goal is to strengthen the health services provided by GPs in the field of mental health\u0026rdquo; and \u0026ldquo;The aim is to achieve better treatment, increased treatment satisfaction among both patients and service providers, and to find a model that is useful and sustainable over time.\u0026rdquo; These are included in the description of the adapted collaborative care model in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. GPs could initiate collaborative care for any of their patients and were not focused on or limited to any specific patient groups or treatments.\u003c/p\u003e \u003cp\u003eThe participating services agreed to initiate the collaborative care project, set to be operational for 18 months starting in early 2016. They also wanted the CMHC to manage the project. It was anticipated that national health authorities would support reimbursement for the collaborative activities in the project, which could potentially demonstrate the advantages of the national health policies focused on enhancing collaboration among health services and treatments provided by GPs and primary care. At the conclusion of the 18-month trial period, the participating services would determine whether and how the collaborative care model should continue.\u003c/p\u003e \u003cp\u003eSeveral practical issues were clarified at this stage, including staffing, office space for the mental health specialists from the CMHC, the organisation of the collaboration, access to electronic patient records, and applying to the national health authorities regarding reimbursement for collaborative activities. It was agreed that a joint project group led by the CMHC and with members of the participating services in each of the three boroughs would further refine the model and determine how it could best be introduced in the practices. This work took three months, and the final adapted model is described below and in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eThe adapted collaborative care model\u003c/h2\u003e \u003cp\u003eThe adapted model consisted of two major components. \u003cb\u003eThe core component\u003c/b\u003e was a collaborative team co-located at each GP practice and consisting of the GPs and a half-time psychologist and a visiting psychiatrist (for two hours a week) from the CMHC. Office space was provided on-site, and the GPs and mental health specialists could easily contact each other to discuss a specific patient, a clinical issue, medications or a referral to another service. The mental health specialists provided assessments and short-term therapies for patients that the GPs referred to them, and the GP occasionally sat in on a consultation. Both GPs and mental health specialists had access to the patients\u0026rsquo; electronic patient records and wrote their notes and summaries of assessments and treatments in the same electronic record.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe extension component\u003c/b\u003e included the involvement of and collaboration with additional professionals from the borough\u0026rsquo;s other primary care, including addiction services and specialised mental health services, meeting regularly or on an ad hoc basis to discuss specific patients or situations. This extension of the collaborative care team allowed for the flexible utilisation of expertise from a wider range of services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eTheory of change for the model as a complex intervention\u003c/h2\u003e \u003cp\u003eRecognising collaborative care as a complex intervention, the assumed mechanism or theory of change for the model would be that close interaction between co-located service providers with different expertise would facilitate establishing and utilising relationships, learning from each other while working together, and providing more comprehensive and earlier assessments and treatments for patients with developing mental health problems. For GPs, this would include learning to better detect and manage mental health problems. See Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe model did not include formal training in new competencies but assumed that participating GPs and mental health professionals would learn from each other as the project progressed. The implementation of the adapted collaborative care model focused on the process of collaboration and integrating mental health professionals in primary care, rather than on specific treatments to be employed. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInsert Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eImplementation and experiences of the collaborative care model\u003c/h2\u003e \u003cp\u003eThe collaborative care teams were established during the winter of 2016 and were operational for 18 months from March/April 2016 to October 2017.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eImplementation of the collaborative care model\u003c/h2\u003e \u003cp\u003eThe collaboration activities of the team to implement the core component were as follows. The GPs initiated ad hoc discussions on patients or clinical issues, joint meetings with patients, and referred patients to the psychologist for assessment or therapy by reserving time in the psychologist\u0026rsquo;s schedule. The GPs demonstrated a keen interest in evaluating and treating patients with mental health challenges, although there was some variation in this interest among the different GPs.\u003c/p\u003e \u003cp\u003eThe therapeutic work of the psychologists was similar across the GP practices, providing short-term therapy much like in the CMHC outpatient clinic. On average the psychologists saw five patients per day, with a range from three to eight. Some patients referred by the GPs to the psychologists for therapy were deemed too ill for short-term therapy and they recommended a referral to the CMHC instead. Situations like these increased the GPs\u0026rsquo; knowledge and experience in determining whom and where to refer and what information to include in referrals.\u003c/p\u003e \u003cp\u003eAll three psychologists experienced fluctuations in the collaboration over time, with some initial challenges and frustrations while introducing the model, followed by a period of successful collaboration. Two positive turning points were identified - one when the psychologists began reporting more positively about collaboration and workload, feeling integrated into the collaborative care team rather than being viewed as external professionals; and a second when the GPs stopped expressing concerns about the uncertainty regarding reimbursements for collaboration activities (see below). Challenges could arise, however, when GP substitutes replaced the GPs in the practices during summer holidays. One psychologist also found on return from a one-month leave that the GPs were reluctant to attend collaborative care team meetings and were referring an excessive number of patients to be seen instead.\u003c/p\u003e \u003cp\u003eIn the beginning the psychiatrist was assigned two hours a week at each of the three GP practices, but over time this was adjusted to respond to specific needs, spending less time in a practice with lower needs and additional time during a psychologist\u0026rsquo;s leave in another practice. The psychiatrist primarily assisted the GPs with reviews of the use and adjustments of psychotropic medications in specific patients, including long-term injectables, seeing the person if further clarification was needed. This increased the GPs\u0026rsquo; competence and comfort in prescribing these medications. The psychiatrist observed that the GPs increasingly became more aware of the need to review long term medications and detect and manage mental health issues that were concurrent with physical symptoms.\u003c/p\u003e \u003cp\u003eThe psychiatrist also responded to questions from the psychologists about medications, usually meeting the patient together. They also assisted the psychologists with more complex cases, sometimes assessing the patient in person (along with the psychologist) and sometimes just by providing advice regarding further treatment options or referral to the CMHC.\u003c/p\u003e \u003cp\u003e In addition, the psychologists established contacts with the municipal primary care and substance abuse services in their boroughs, and the local Employment and Welfare Administration. In one borough, the psychologist spent half a day weekly with their primary mental health care service, meeting with and supervising personnel and seeing some patients. In the two other boroughs, the psychologist\u0026rsquo;s contact with primary care was as needed. However, few of the borough service providers participated in the joint semi-annual collaborative meetings to discuss their experiences and future directions for the collaboration, indicating a possible lack of engagement.\u003c/p\u003e \u003cp\u003eMental health specialists from CAMHS and the outpatient clinic for substance abuse in the specialised mental health services could also be included when needed. It was soon concluded, however, that this was not necessary, as the GPs had well-established collaboration with these services and could easily contact them when needed.\u003c/p\u003e \u003cp\u003eWider stakeholder involvement in the project was more limited than intended. A service user representative from the local group of the national user organisation Mental Health was recruited to one of the collaborative care teams. She was involved in team meetings regarding the collaboration but not clinical meetings about specific patients. In the two other GP practices, the project was unsuccessful in recruiting service user representatives to the teams, or in involving family caregivers in the planning or implementation.\u003c/p\u003e \u003cp\u003eThere were some differences in contexts and local adaptions of the collaborative care model across the three GP practices, designated as team A, B, and C. In Team A (with 4 GPs) initial reactions to the project were mixed. While the GPs became increasingly positive over time, some remained hesitant to participate in collaborative meetings and patient discussions. Each GP in Team A had separate funding, which might have contributed to difficulties in forming joint plans for the entire group. Collaboration with the borough services was most systematic in Team A, where the manager in the borough's primary mental health care team engaged several local services in a weekly half-day session with the psychologist for supervision and case reviews.\u003c/p\u003e \u003cp\u003eTeam B (with 3 GPs) was the most integrated team, holding monthly meetings and regularly engaging in productive dialogues and joint case discussions. The psychologist and psychiatrist found it easy to discuss patients with the GPs after consultations, and each GP often allocated time to discuss medication with the psychiatrist. The project was seen to enhance local collaboration across various services, service levels, and disciplines.\u003c/p\u003e \u003cp\u003eTeam C (with 4 GPs) felt they had less needs for collaboration with the borough primary care services. This may have been due to fewer socioeconomic problems in their part of the borough and because they treated many patients from outside the borough. Patients referred to the psychologist tended to have fewer complex issues compared to those in the other teams, with fewer referrals to the psychiatrist for medication reviews. The borough provided low threshold \"rapid mental health care\" services with psychologists, allowing the team\u0026rsquo;s psychologist to refer patients when pressed for time. Team meetings were less frequent in Team C.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eExperiences with the collaborative care model\u003c/h2\u003e \u003cp\u003eThe GPs expressed satisfaction with the model and wanted to see it continue. They noted several benefits, including shorter waiting times for mental health care and greater accessibility when care was provided within their practices. Additionally, they experienced personal gains, such as heightened awareness of mental health issues and increased confidence in assessing and managing mental health problems. They also gained a better understanding of the services offered by the CMHC and the borough, feeling that the personal relationships developed with personnel from other services facilitated easier collaboration.\u003c/p\u003e \u003cp\u003eThe psychologists and psychiatrist also reported positive experiences with the model. They gained insights into GP work, the comorbidity of mental and physical illnesses, the treatment of physical health issues, and the available borough services. Compared to their experiences in the outpatient clinic, they saw that clinical improvements could occur more rapidly, as they were able to engage with patients at an earlier stage when problems might be less severe.\u003c/p\u003e \u003cp\u003e Healthcare professionals in the borough's services had diverse experiences with the collaborative care model. Some had participated in the visit to Hamilton and were familiar with the model, while others needed more time to understand how borough services could be involved in collaborative care. Variations in population needs and the organisation of borough services also impacted their participation. Overall, the participating borough services appreciated having a common meeting point to familiarise themselves with each other, understand one another's practices, discuss issues, and learn about other services. They also recognised that greater utilisation could have been made of borough services such as the \"rapid back to work\" mental health program, the local Employment and Welfare Administration, and substance abuse primary care if they had been more involved and found ways to contribute their specific expertise.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eChallenges in the implementation of collaborative care\u003c/h2\u003e \u003cp\u003eThree significant barriers to implementation were identified: the workload of the psychologists, the GPs\u0026rsquo; lack of time to attend meetings, and uncertainty about reimbursement for collaborative activities at GP practices.\u003c/p\u003e \u003cp\u003eInitially, the psychologists' workload was overwhelming, as they were assigned too many patients per day. As their schedules began to fill weeks in advance, their ability to schedule new appointments for patients needing more therapy became limited. This issue was resolved by allowing psychologists to take more control over their schedules, restrict the number of patients seen per day, and use a scheduling block function to reserve slots for future therapy sessions. These adjustments were made after discussions with the GPs at their practices.\u003c/p\u003e \u003cp\u003eGPs' lack of time for attending collaboration meetings was a recurring issue, as their increasing administrative workload limited the available time for meetings.\u003c/p\u003e \u003cp\u003eFinancial challenges emerged early in the planning phase, as implementing the model without additional funding presented significant difficulties for the participating services. GP practices incurred various expenses, including office space, access to electronic patient records, and secretarial support, in addition to the time dedicated to collaboration. For the CMHC, assigning two full-time staff equivalents to collaborate with the three GP practices reduced the number of consultations that could be provided at the outpatient clinic, thus increasing the workload for other clinical staff and potentially impacting annual funding.\u003c/p\u003e \u003cp\u003eIt was unclear from the outset whether GPs could be reimbursed for patient consultations conducted by the psychologist or for time spent on collaborative activities, and patients could not be charged fees for consultations not eligible for reimbursement. Similarly, the CMHC could not charge fees or obtain reimbursement for patients seen by a psychologist or psychiatrist at a GP's practice.\u003c/p\u003e \u003cp\u003eIt was anticipated that national health authorities would recognise the CRCT\u0026rsquo;s value in relation to national health policy and offer flexibility regarding reimbursement during the 18-month implementation phase. Despite multiple requests over time to increasing higher levels of national health authorities, no special reimbursement arrangements were made. Consequently, the collaboration had to proceed without reimbursement for collaborative activities, causing significant frustration for participants and prompting discussions about the implications for long-term sustainability.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eConclusion regarding sustainability of the model\u003c/h2\u003e \u003cp\u003eUltimately, despite the successful implementation and positive experiences of the collaborative care model, the lack of reimbursement for collaborative activities led both the GP practices and the CMHC to conclude that the model could not be sustained beyond the 18-month implementation phase, without additional funding. The financial losses made it impossible for the GP practices to continue, and the CMHC lacked the economic and human resources to maintain the collaboration model or expand it to additional GP practices. The borough services had not committed any specific resources and were not involved in the decision to discontinue the collaborative care model.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eThe implementation of the model\u003c/h2\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eCharacteristics of the complex intervention\u003c/h2\u003e \u003cp\u003eThe core component of the adapted model was successfully implemented and perceived as beneficial. GPs and mental health specialists effectively utilised their complementary knowledge and skills to meet the diverse needs of different patients, while simultaneously enhancing their own competencies. All three participating teams successfully integrated the primary elements of the model. The variations observed across the three practices showcased the model's flexibility, allowing it to be tailored to meet specific local contexts and needs (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA qualitative study exploring the experiences of GPs and mental health specialists with the model identified key factors contributing to its success: the co-location and the mental health specialist acting as a front-line contact (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). This supports the assumption that the mechanism in this complex intervention was the close collaboration between co-located GPs and mental health specialists with complementary expertise.\u003c/p\u003e \u003cp\u003eAs in Hamilton, the collaboration addressed a wide range of problems, unlike many other collaborative care models that focus on a specific diagnostic group or treatment (\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e–\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). In the current study, the psychologist also offered ad hoc meetings with the GPs, assessments, and short-term therapy options. Unlike in Hamilton, the current project implemented the adapted model without establishing a new administrative organisation. This facilitated the initiation of implementation without requiring organisational changes, which would have been difficult to achieve within the existing structure of Norwegian health services.\u003c/p\u003e \u003cp\u003eThe extension component of the model was also flexible, depending upon how borough services were organised and what each could contribute to collaborative care. Unlike the core component, however, which involved only a few individuals at each practice, implementing the extension component proved more challenging. It necessitated the involvement of a wide range of services across various locations, with multiple teams and professionals who also needed to coordinate with other GP practices within the borough.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eOuter setting and inner setting factors affecting the collaboration\u003c/h2\u003e \u003cp\u003eThe major barrier to the sustainability of the collaborative care model in the Norwegian context was the lack of financial reimbursement for collaborative activities between primary and specialised health care, reflecting the separate funding systems for these two healthcare sectors. Although recent national health policies aim to reduce fragmentation, boost collaboration, and enhance the roles of GPs and other primary care providers, the financial system currently undermines these objectives, discouraging collaboration in GP practices (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo resolve this, health service funding needs to better align with national health policy goals. Our previous paper on the model’s effect on sick leave and work assessment allowance indicates that the model may offer substantial economic benefits for the society (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). While days of patients’ (short-term) sick leave increased by 4% in collaborative care practices compared to control practices, subsequent days receiving longer time work assessment allowance decreased by 8%, and these changes came from the patients with mental health problems. This indicates that early identification and treatment (including sick leave) of mental health problems leads to a better long-term prognosis with a reduction in long term work assessment allowance, and probably in disability pension.\u003c/p\u003e \u003cp\u003e Based on the HFHT model, we found that having a half-time psychologist and a visiting psychiatrist for two hours weekly at each GP practice created a viable collaborative care team. This arrangement matched the resources available from the CMHC and the support the GP practices could offer regarding office space and logistics. With each practice having 3–4 GPs, the consistent staffing of mental health specialists across the three practices was effective and remained unchanged throughout the project. Additionally, the weekly half-day commitment from the psychologist for collaboration and clinical supervision with the borough proved successful.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eThe implementation process\u003c/h2\u003e \u003cp\u003eSome aspects of the implementation process could have been improved. Service users, family caregivers, and borough service providers had limited involvement, leading to GPs and mental health specialists dominating planning and implementation. Engaging borough service managers more actively, perhaps through joint leadership, might have boosted participation.\u003c/p\u003e \u003cp\u003eTraining on collaboration principles and practices during the preparation phase might have strengthened involvement, though it would have required additional time for participating service providers. GPs and mental health specialists deemed such training unnecessary, as the model’s core component utilised their existing competencies to address issues as they arose. No external supervision was provided for the collaborative care teams, except for project meeting discussions at the CMHC involving psychologists and psychiatrists.\u003c/p\u003e \u003cp\u003eAlthough the 18-month implementation period was sufficient to demonstrate the potential benefits of the collaborative care model, it was not long enough to develop and test adjustments that might have led to a more sustainable model, unlike the HFHT model that evolved over many years (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In retrospect, the issue of financing for collaborative activities should have been clarified before the start of the implementation. Without this, the project became more of a pilot aimed at testing and promoting the model, rather than a fully sustainable, scalable exercise. Involving all stakeholders over a longer period before start might have identified further adjustments that needed to be made to facilitate scalability. On the other hand, knowing earlier that the anticipated reimbursements would not be provided, might have led to the cancellation of the implementation, thereby forfeiting the opportunity to understand how the model could function in practice.\u003c/p\u003e \u003cp\u003eNo systematic process evaluation plan was drafted during the planning phase, as the focus at that time was on testing the adapted collaborative care model in a CRCT. Collecting data on informal aspects, like ad hoc meetings, would also have been difficult. If resources had permitted, an external expert evaluation might have added credibility. Nevertheless, when conducting the evaluation, the research team was able to build on their knowledge of the implementation process across all phases, drawing upon their expertise in relevant clinical work, collaboration, and health services research. While the research group may have been biased when using their expertise in discussing factors affecting the implementation of the model, the implementation and the experiences of the collaborative care were documented in minutes and summaries from meetings and workshops. In addition to the two workshops with the participating services after the 18 months, the research group presented the results from the published papers and this evaluation during visits to the GP practices, where the participating GPs reviewed, recognised and confirmed the findings.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAdjustments to make the model sustainable\u003c/h3\u003e\n\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eSuggested adjustments of the model under current financial circumstances\u003c/h2\u003e \u003cp\u003eDuring workshops held at the end of the project, the participants and the research group discussed several potential adjustments to make the model more sustainable under current circumstances. One suggestion was to reduce the time that the mental health specialists spend in GP practices, as had been the case with a similar model employed by the CMHC in previous years. This approach also aligns with the model practised by the project lead (a psychiatrist), who had previously visited 20 GPs and other primary care services across six municipalities in a CMHC catchment area, dedicating one full day every week to this over 15 years (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Reducing the psychologists’ time providing short-term therapies would also enhance the model's viability. Video meetings and other electronic communication methods, which gained prominence during the Covid-19 pandemic, could also be utilised (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). In addition, training GPs in specific skills, such as cognitive-behavioural therapy, might also be considered as an adjustment to the model. CBT is increasingly used in many GP practices in Norway and other countries (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCollaboration and communication could also be enhanced by holding regular clinical meetings between GPs, primary care providers, and mental health specialists to discuss specific cases and support the service providers involved. These meetings could improve continuity of care, strengthen relationships between GPs, primary care, and specialised mental health services, and increase their skills. Larger, less frequent meetings involving all service providers could focus on broader system issues, such as service provision, capacities, expectations, and fostering collaboration procedures. Ways of improving patient transfers between services could include preparing the patient appropriately, sending early referrals, sharing information about previous treatments, suggesting further treatment, and organising joint transfer meetings with the patient and involved services. Mutual understanding and collaboration among healthcare workers could also be strengthened through internships or mutual visiting arrangements between services and joint educational events.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003ePolicy changes needed for more extensive collaboration\u003c/h2\u003e \u003cp\u003eFor collaboration to succeed, it is crucial for the government and national health authorities to recognise collaborative care with GPs as a mandatory responsibility of specialists working within specialised mental health services. This recognition should be supported by financial incentives. For instance, GP practices could be reimbursed for treatment sessions involving mental health specialists working alongside GPs, as well as for internal interprofessional meetings to discuss cases, similar to how meetings with other service providers are reimbursed. Other countries provide examples of how collaborative care can be financed (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSuch measures would align with recommendations from the World Health Organisation and the experiences of many countries that have integrated mental health care within primary care settings (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). In Norway, a government-appointed expert committee has recently provided advice on the thematic organisation of mental health services, including collaboration between GPs, primary health care, and specialised mental health care, referencing the results and experiences of our project (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Enhancing collaboration between mental health and primary care services can also be facilitated by changes in organisational functioning, as highlighted in a recent joint position paper from the Canadian Psychiatric Association and the College of Family Physicians of Canada (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eOne of the strengths of the process evaluation was the ability to compare the adapted collaborative care model with a well-established one, which has evolved and been sustained over three decades. Reviewing written minutes and notes from the planning, preparation, and implementation phases provided valuable documentation of the steps taken. The results from the process evaluation and the experiences gained from the model will be useful for interpreting the primary outcomes of the CRCT. However, a significant limitation was the absence of a systematic plan for the process evaluation during the planning of the CRCT. This oversight resulted in limited data collection on various aspects of the implementation, such as the involvement of borough services and ad hoc meetings between GPs and mental health specialists.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion and implications","content":"\u003cp\u003e The core component of a collaborative care model between co-located GPs and mental health specialists was successfully implemented and was seen by the participating service providers as an improvement in the delivery of health care. However, it proved unsustainable due to the lack of reimbursement for collaborative activities and associated costs. The extension component, which involved collaborating with other borough services, was only partially implemented, more so in one borough and less in two, possibly because they weren’t more fully involved at the start of the project. The results indicate that the sustainability of such a model relies on reimbursing GPs for collaborative activities and formally recognising that closer working relationships with GP practices should be integral to specialised mental health services. It is crucial to tailor the range of collaborative activities to available resources, especially given the limited capacity to co-locate mental health specialists within GP practices. Achieving more extensive collaboration may require organisational and practice changes at national, regional, and local levels.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCAMHS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Child and Adolescent Mental Health Services\u003c/p\u003e\n\u003cp\u003eCBT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Cognitive Behavioural Therapy\u003c/p\u003e\n\u003cp\u003eCMHC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Community Mental Health Centre\u003c/p\u003e\n\u003cp\u003eCRCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Cluster-randomised controlled trial\u003c/p\u003e\n\u003cp\u003eGP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;General Practitioner\u003c/p\u003e\n\u003cp\u003eHFHT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Hamilton Family Health Team\u003c/p\u003e\n\u003cp\u003eICPC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;International Classification of Primary Care\u003c/p\u003e\n\u003cp\u003eIT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Information technology\u003c/p\u003e\n\u003cp\u003eUK MRC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;UK Medical Research Council\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical approvals\u003c/p\u003e\n\u003cp\u003eThe CRCT received the necessary approvals from The Regional Committee for Medical and Health Research Ethics South-East (REC, reg. no. 2014/435), The National Committee for Medical and Health Research Ethics (NEM, reg. no. 2014/160), and the Data Protection Officer at Akershus University Hospital (reg. no. 2013-138).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten informed consent to participate in the CRCT was obtained for patients completing a questionnaire at GP practices during a two-weeks data collection, and REC and NEM granted exemption from confidentiality to extraction of some specified structured data from the electronic patient records in GP practices for the previous 12 months. The current study did not use any patient data or any personal information on health personnel. The four mental health specialists that may be identified by someone knowing the study well, have given consent to publishing the study. Such studies without personal information on patients or others do not need ethical approval from REC and NEM according to Norwegian law. The study adhered to the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical trial number\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe study was partially funded by the Regional Health Authority South-East (project no. 2013132). The work of the authors was done as a part of their job at their affiliations.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo;\u0026nbsp;contributions\u003c/p\u003e\n\u003cp\u003eTR conceived the study, was principal investigator, planned the paper, and drafted the manuscript. AH contributed to planning the study, was consultant psychiatrist in the three collaborative teams, and participated in the project meetings during the implementation. JR, ORH and MPD contributed to planning the study. All authors (including KHB, MB, OGT, NK) contributed to writing and revisions of the manuscript and read and approved the final manuscript for submission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe are grateful to the health workers in the participating services for their efforts in implementing the adapted collaborative care model and for their input to the process evaluation by communicating their experiences with the model and suggesting adjustments to make it more sustainable. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLampe L, Shadbolt N, Starcevic V, Boyce P, Brakoulias V, Hitching R, et al. Diagnostic processes in mental health: GPs and psychiatrists reading from the same book but on a different page. Australas Psychiatry. 2012;20(5):374-8.\u003c/li\u003e\n\u003cli\u003eKlimas J, Neary A, McNicholas C, Meagher D, Cullen W. 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Comparative effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings: Systematic Review and Meta-Analysis. Am J Psychiatry. 2012;169(8):790-804.\u003c/li\u003e\n\u003cli\u003eZanaboni P, Fagerlund AJ. Patients\u0026apos; use and experiences with e-consultation and other digital health services with their general practitioner in Norway: results from an online survey. BMJ Open. 2020;10(6):e034773.\u003c/li\u003e\n\u003cli\u003eHaavet OR, Myhrer KS, Kates N, Mdala I, Aschim B, Lundevall S, et al. Impact of a cognitive behavioural therapy training program on family physician practices Cross-sectional study in Norway. Canadian Family Physician. 2023;69:784-91.\u003c/li\u003e\n\u003cli\u003eTruelove S, Ng V, Kates N, Alloo J, Sunderji N, Patriquin MJ. Collaborative mental health care. Engaging health systems to support a team-based approach. Canadian family physician. 2023;69(2):81-3.\u003c/li\u003e\n\u003cli\u003eWolk CB, Alter CL, Kishton R, J. R, Atlas JA, Press MJ, et al. Improving Payment for Collaborative Mental Health Care in Primary Care. Med Care. 2021;59:324-6.\u003c/li\u003e\n\u003cli\u003eWHO. Mental health in primary care: Illusion or inclusion? Geneva: World Health Organization 2018.\u003c/li\u003e\n\u003cli\u003eHelse-_og_omsorgsdepartementet. Forenkle og forbedre. Rapport fra ekspertutvalg for tematisk organisering av psykisk helsevern [Simplify and improve. Report from the expert committee for thematic organization of mental health care. Report from the expert committee appointed by the Ministry of Health and Care Services. Oslo; 2023.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Collaborative care, mental health, general practice, implementation, sustainability","lastPublishedDoi":"10.21203/rs.3.rs-6030253/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6030253/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePrevious studies have shown that collaboration between primary care and mental health services can enhance accessibility and improve outcomes for patients seen in general practitioners (GPs\u0026rsquo;) office. There is, however, a lack of empirical evidence regarding the benefits of collaborative care in Norway. This study, part of a larger research project, examined the adaptation and implementation of a successful Canadian collaborative care model developed in Hamilton, Ontario, in three Norwegian GP practices located in different boroughs of Oslo, Norway's largest city.\u003c/p\u003e\u003ch2\u003eAims\u003c/h2\u003e \u003cp\u003eTo evaluate the required adaptations, implementation, challenges, and sustainability of the Hamilton model within the Norwegian context.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe overarching study was a cluster-randomised trial testing the adapted model in three urban GP practices over an 18-month period, with three additional GP practices from the same boroughs serving as control groups. Each intervention site included a half-time clinical psychologist from the local community mental health centre and a psychiatrist who visited for two hours each week. The project also aimed to extend collaboration to other health and community services within each borough. This paper evaluates the implementation of the project's intervention arm, using inductive thematic analysis of documents from all of the project\u0026rsquo;s phases and following recommendations for process evaluation of complex interventions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe model's core component\u0026mdash;collaboration between GPs and mental health specialists\u0026mdash;was successfully implemented. Participating GPs appreciated the convenient access to mental health specialists to assist with managing mental health problems, although they faced challenges in finding time for collaboration. However, health policy restrictions on providing financial support for co-located collaborative care rendered the model unsustainable beyond the trial period and impeded its expansion to further GP practices.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe model was successfully implemented and viewed as an improvement in healthcare delivery. If such a model is to be sustained, adjustments must be made to align it with available resources, and reimbursements are needed for collaborative activities in GP practices. It also requires a recognition by funders and planners of the benefits of co-locating specialised mental health specialists within GP practices.\u003c/p\u003e","manuscriptTitle":"A collaborative primary and mental health care model with psychologist and psychiatrist working in GP practices: Process evaluation of the implementation, challenges, and sustainability","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-10 09:02:38","doi":"10.21203/rs.3.rs-6030253/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-25T11:04:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-19T00:17:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"107746856306689011266594395275531268004","date":"2025-06-15T22:54:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"156296595186204410462775690455726132213","date":"2025-06-11T15:31:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-11T18:35:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138354716301861623316459617623123025260","date":"2025-04-07T07:59:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-04T15:17:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-01T09:53:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-03-31T15:43:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"07d5bd0a-ada9-4c7e-8faf-f159aa131793","owner":[],"postedDate":"April 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T15:58:27+00:00","versionOfRecord":{"articleIdentity":"rs-6030253","link":"https://doi.org/10.1186/s12913-025-13408-y","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-09-02 15:56:57","publishedOnDateReadable":"September 2nd, 2025"},"versionCreatedAt":"2025-04-10 09:02:38","video":"","vorDoi":"10.1186/s12913-025-13408-y","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13408-y","workflowStages":[]},"version":"v1","identity":"rs-6030253","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6030253","identity":"rs-6030253","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}