Depressed Older Patients’ Need for and Expectations of Improved Health Services—An Evaluative Approach to the Chronic Care Model
Affiliation(s)
1 Centre for Women’s, Family and Child Health, Faculty of Health Sciences, Buskerud and Vestfold University College, Kongsberg, Norway. 2 Department of Nursing, Health and Culture, University West, Trollhättan, Sweden. 3 Department of Health Science, Stord/Haugesund University College, Stord, Norway.
1 Centre for Women’s, Family and Child Health, Faculty of Health Sciences, Buskerud and Vestfold University College, Kongsberg, Norway. 2 Department of Nursing, Health and Culture, University West, Trollhättan, Sweden. 3 Department of Health Science, Stord/Haugesund University College, Stord, Norway.
ABSTRACT
Depression in later life is an underrepresented yet important research area. The aim of the study was to explore depressed older persons’ need for and expectations of improved health services one year after implementation of the Chronic Care Model (CCM). A qualitative evaluative design was used. Data were collected through individual interviews with older persons living in Norway. The qualitative content analysis revealed two themes: The need to be safeguarded and Expectation of being considered valuable and capable. Evaluation of the improvement in care with focus on the CCM components showed that the most important components for improving the depressed older person’s daily life were: delivery system re-design, self-management support, productive interaction and a well-informed active patient. The findings highlight the need for a health services designed for persons suffering from chronic ill-health, where the CCM could serve as a framework for policy change and support the redesign of the existing healthcare system. We conclude that older persons with depression need attention, especially those who have been suffering for many years. The identified components may have implications for health professionals in the promotion of mental healthcare.
Depression in later life is an underrepresented yet important research area. The aim of the study was to explore depressed older persons’ need for and expectations of improved health services one year after implementation of the Chronic Care Model (CCM). A qualitative evaluative design was used. Data were collected through individual interviews with older persons living in Norway. The qualitative content analysis revealed two themes: The need to be safeguarded and Expectation of being considered valuable and capable. Evaluation of the improvement in care with focus on the CCM components showed that the most important components for improving the depressed older person’s daily life were: delivery system re-design, self-management support, productive interaction and a well-informed active patient. The findings highlight the need for a health services designed for persons suffering from chronic ill-health, where the CCM could serve as a framework for policy change and support the redesign of the existing healthcare system. We conclude that older persons with depression need attention, especially those who have been suffering for many years. The identified components may have implications for health professionals in the promotion of mental healthcare.
Cite this paper
Lyberg, A. , Berggren, I. , Holm, A. and Severinsson, E. (2015) Depressed Older Patients’ Need for and Expectations of Improved Health Services—An Evaluative Approach to the Chronic Care Model. Open Journal of Nursing, 5, 376-386. doi: 10.4236/ojn.2015.54041.
Lyberg, A. , Berggren, I. , Holm, A. and Severinsson, E. (2015) Depressed Older Patients’ Need for and Expectations of Improved Health Services—An Evaluative Approach to the Chronic Care Model. Open Journal of Nursing, 5, 376-386. doi: 10.4236/ojn.2015.54041.
References
[1] World Health Organization (2012) Depression Is a Common Illness and People Suffering from Depression Need Support and Treatment.
http://www.who.int/mediacentre/news/notes/2012/mental_health_day_20121009/en/ [2] World Health Organization (2004) Global Burden of Disease.
http://www.who.int/healthinf/global_burden_disease/GBD_report_2004update_full.pdf [3] Sirey, J.A., Bruce, M.L. and Alexopoulous, G.S. (2005) The Treatment Initiation Program: An Intervention to Improve Depression Outcome in Older Adults. American Journal of Psychiatry, 162, 184-186.
http://dx.doi.org/10.1176/appi.ajp.162.1.184 [4] Drayer, R., Mulsant, B., Lenze, E., Rollman, B.L., Dew, M.A., Kelleher, K., Karp, J.F., Begely, A., Schulberg, H. and Reynolds, C.F. (2005) Somatic Symptoms of Depression in Elderly Patients with Medical Comorbidities. International Journal of Geriatric Psychiatry, 20, 973-982.
http://dx.doi.org/10.1002/gps.1389 [5] Hitchcock, N.P., Williams, J., Unützer, J., Worchel, J., Shuko, L., Cornell, J., Katon, W., Harpole, L. and Hunkler, E. (2004) Depression and Comorbid Illness in Elderly Primary Care Patients: Impact on Multiple Domains of Health Status and Well-Being. Annals of Family Medicine, 2, 555-562.
http://dx.doi.org/10.1370/afm.143 [6] Callahan, C. (2001) Quality Improvement Research on Late Life Depression in Primary Care. Medical Care, 39, 722-784.
http://dx.doi.org/10.1097/00005650-200108000-00004 [7] Djernes, J.K. (2006) Prevalence and Predictors of Depression in Populations of Elderly: A Review. Acta Psychiatrica Scandinavia, 113, 372-387.
http://dx.doi.org/10.1111/j.1600-0447.2006.00770.x [8] Robinson, W.D., Bischoff, R., Geske, J. Backer, E., Olson, M., Jarzynka, K. and Swinton, J. (2012) Rural Experiences with Mental Illness: Through the Eyes of Patients and their Families. Families, Systems, & Health, 30, 308-321.
http://dx.doi.org/10.1037/a0030171 [9] Holm, A.L., Lyberg, A. and Severinsson, E. (2014) Living with Stigma: Depressed Elderly Persons’ Experiences of Physical Health Problems. Nursing Research and Practice, 2014, Article ID: 527920.
http://dx.doi.org/10.1155/2014/527920 [10] Zeng, W., North, N. and Kent, B. (2012) A Framework to Understand Depression among Older Persons. Journal of Clinical Nursing, 21, 2399-2409.
http://dx.doi.org/10.1111/j.1365-2702.2011.04049.x [11] Allan, J. and Dixon, A. (2009) Older Women’s Experiences of Depression: A Hermeneutic Phenomenological Study. Journal of Psychiatric and Mental Health Nursing, 16, 865-873.
http://dx.doi.org/10.1111/j.1365-2850.2009.01465.x [12] Lyberg, A., Holm, A.L., Lassenius, E., Berggren, I. and Severinsson, E. (2013) Older Persons’ Experiences of Depressive Ill-Health and Family Support. Nursing Research & Practice, 2013, Article ID: 837529.
http://dx.doi.org/10.1155/2013/837529 [13] Chew-Graham, C., Kovandzic, M., Gask, L., Burroughs, H., Clarke, P., Sanderson, H. and Dowrick, C. (2012) Why May Older People with Depression Not Present to Primary Care? Messages from Secondary Analysis of Qualitative Data. Health & Social Care in the Community, 20, 52-60.
http://dx.doi.org/10.1111/j.1365-2524.2011.01015.x [14] Fixsen, D.L., Blasé, K.A., Naoom, S.F. and Wallace, F. (2009) Core Implementation Components. Research on Social Work Practice, 19, 531-540.
http://dx.doi.org/10.1177/1049731509335549 [15] World Health Organization (2008) Caring for People with Chronic Conditions: A Health System Perspective.
http://apps.who.int/iris/bitstream/10665/112830/1/9789241506793_eng.pdf?ua=1 [16] Bodenheimer, T., Wagner, E.H. and Grumbach, K. (2002) Improving Primary Care for Patients with Chronic Illness. The Chronic Care Model. The Journal of the American Medical Association, 288, 1775-1779.
http://dx.doi.org/10.1001/jama.288.14.1775 [17] Bodenheimer, T., Wagner, E.H. and Grumbach, K. (2002) Improving Primary Care for Patients with Chronic Illness. The Chronic Care Model, Part 2. The Journal of the American Medical Association, 288, 1909-1914.
http://dx.doi.org/10.1001/jama.288.15.1909 [18] Wagner, E.H., Glasgow, R.E., Davis, C., Bonomi, A.E., Lloyd, P., McCulloch, D., Carver, P. and Sixta, C. (2001) Quality Improvement in Chronic Illness Care: A Collaborative Approach. Joint Commission Journal on Quality Improvement, 27, 63-80. [19] Holm, A.L., Lyberg, A., Lassenius, E., Berggren, I. and Severinsson, E. (2013) Older Persons’ Lived Experiences of Depression and Self-Management. Issues in Mental Health Nursing, 34, 757-764.
http://dx.doi.org/10.3109/01612840.2013.809829 [20] Holm, A.L., Lyberg, A., Berggren, I., Cutcliffe, J. and Severinsson, E. (2014) Shadows from the Past—The Situated Meanings of Being Suicidal among Depressed Older People Living in the Community. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 35, 253-260.
http://dx.doi.org/10.1027/0227-5910/a000259 [21] Holm, A.L. and Severinsson, E. (2014) Surviving Depressive Ill-Health: A Qualitative Systematic Review of Older Person’s Narratives. Nursing & Health Sciences, 16, 131-140.
http://dx.doi.org/10.1111/nhs.12071 [22] Holm, A.L. and Severinsson, E. (2013) Interdisciplinary Team Collaboration during Discharge of Depressed Older Persons: A Norwegian Qualitative Implementation Study. Nursing Research and Practice, 2013, Article ID: 794743.
http://dx.doi.org/10.1155/2013/794743 [23] Holm, A.L. and Severinsson, E. (2014) Perceptions of the Need for Improvements in Healthcare after Implementation of the Chronic Care Model. Nursing & Health Sciences, 16, 442-448.
http://dx.doi.org/10.1111/nhs.12136 [24] Severinsson, E. and Holm, A.L. (2014) Chronic Disease Management: Implementation and Coordination of Healthcare Systems for Depressed Elderly Persons. Issues in Mental Health Nursing, 35, 934-939.
http://dx.doi.org/10.3109/01612840.2014.930215 [25] Holm, A.L., Lyberg, A., Berggren, I., Åström, S. and Severinsson, E. (2014) Social Capital and Depressive Ill Health—An Evaluative Approach to the Implementation of the Chronic Care Model. Open Journal of Nursing, 4, 683-694.
http://dx.doi.org/10.4236/ojn.2014.410073 [26] Holm, A.L., Lyberg, A., Berggren, I. and Severinsson, E. (2014) Shared Decision-Making after Implementation of the Chronic Care Model (CCM)—An Evaluative Approach. Open Journal of Nursing, 4, 824-835.
http://dx.doi.org/10.4236/ojn.2014.412088 [27] Severinsson, E. and Holm, A.L. (2014) Understanding and Improving Quality of Care in the Context of Depressed Elderly Persons Living in Norway. Open Journal of Nursing, 4, 809-817.
http://dx.doi.org/10.4236/ojn.2014.412086 [28] Polit, D.F. and Beck, C.T. (2012) Nursing Research: Generating and Assessing Evidence for Nursing Practice. Lippincott Williams & Wilkins, London. [29] Hsieh, H.F. and Shannon, S.E. (2005) Three Approaches to Qualitative Content Analysis. Qualitative Health Research, 15, 1277-1288. [30] Graneheim, U.H. and Lundman, B. (2004) Qualitative Content Analysis in Nursing Research: Concepts, Procedures and Measures to Achieve Trustworthiness. Nurse Education Today, 24, 105-112.
http://dx.doi.org/10.1016/j.nedt.2003.10.001 [31] Sandelowski, M. and Leeman, J. (2011) Writing Usable Qualitative Health Research Findings. Qualitative Health Research, 22, 1404-1413.
http://dx.doi.org/10.1177/1049732312450368 [32] Denzin, N.K. and Lincoln, Y.S. (2008) Collecting and Interpreting Qualitative Materials. Sage, Los Angeles. [33] Elo, S., Käriänen, M., Kanste, O., Pölkki, T., Utriainen, K. and Kyngärs, H. (2014) Qualitative Content Analysis: A Focus on Trustworthiness. SAGE Open, 4, 1-10.
http://dx.doi.org/10.1177/2158244014522633 [34] World Medical Association (2014)
http://www.wma.net/en/30publications/10policies/b3/ [35] Liamputtong, P. (2007) Researching the Vulnerable: A Guide to Sensitive Research Methods. Sage Publisher, London. [36] Laister, S. (2011) Older Adults’ Perceptions of Feeling Safe in an Intensive Unit. Journal of Advanced Nursing, 67, 2649-2657.
http://dx.doi.org/10.1111/j.1365-2648.2011.05714.x [37] The Norwegian Social and Health Department (1997-1998) Stortingsproposisjon No. 63: Opptrappingsplan for psykisk helse 1999-2009. Sosial og Helsedepartementet, Oslo. [38] The Norwegian Research Council (2009) Evaluering av opptrappingsplanen for psykisk helse (2001-2009). Sluttrapportsyntese og analyse av evalueringens delprosjekter. [39] Ahlström, B.H., Skärsäter, I. and Danielsson, E. (2009) Living with Major Depression: Experiences from Families’ Perspectives. Scandinavian Journal of Caring Sciences, 23, 309-316.
http://dx.doi.org/10.1111/j.1471-6712.2008.00624.x [40] Coleman, K., Austin, B.T., Brach, C. and Wagner, E.H. (2009) Evidence on the Chronic Care Model in the New Millennium. Health Affairs, 28, 75-85.
http://dx.doi.org/10.1377/hlthaff.28.1.75 [41] Dorr, D.A., Wilcox, A., Burns, L., Brunker, C.P., Narus, S.P. and Clayton, P.D. (2006) Implementing a Multidisease Chronic Care Model in Primary Care Using People and Technology. Disease Management, 9, 1-15.
http://dx.doi.org/10.1089/dis.2006.9.1 [42] Solberg, L.I., Crain, A.L., Sperl-Hillen, J.M., Hroscikoski, M.C., Engebretson, K.I. and O’Connor, P.J. (2006) Care Quality and Implementation of the Chronic Care Model: A Quantitative Study. Annals of Family Medicine, 4, 310-316. http://dx.doi.org/10.1370/afm.571 [43] Kadu, M.K. and Stolee, P. (2015) Facilitators and Barriers of Implementing the Chronic Care Model in Primary Care: A Systematic Review. BMC Family Practice, 16, 12.
http://dx.doi.org/10.1186/s12875-014-0219-0 [44] Holm, A.L. and Severinsson, E. (2012) Chronic Care Model for the Management of Depression: Synthesis of Barriers to, and Facilitators of Success. International Journal of Mental Health Nursing, 21, 513-523.
http://dx.doi.org/10.1111/j.1447-0349.2012.00827.x [45] Craig, P., Macintyre, S., Michie, S., Nazareth, I. and Petticrew, M. (2008) Developing and Evaluating Complex Interventions: The New Medical Research Council Guidance. British Medical Journal, 337, a1655.
[1] World Health Organization (2012) Depression Is a Common Illness and People Suffering from Depression Need Support and Treatment.
http://www.who.int/mediacentre/news/notes/2012/mental_health_day_20121009/en/ [2] World Health Organization (2004) Global Burden of Disease.
http://www.who.int/healthinf/global_burden_disease/GBD_report_2004update_full.pdf [3] Sirey, J.A., Bruce, M.L. and Alexopoulous, G.S. (2005) The Treatment Initiation Program: An Intervention to Improve Depression Outcome in Older Adults. American Journal of Psychiatry, 162, 184-186.
http://dx.doi.org/10.1176/appi.ajp.162.1.184 [4] Drayer, R., Mulsant, B., Lenze, E., Rollman, B.L., Dew, M.A., Kelleher, K., Karp, J.F., Begely, A., Schulberg, H. and Reynolds, C.F. (2005) Somatic Symptoms of Depression in Elderly Patients with Medical Comorbidities. International Journal of Geriatric Psychiatry, 20, 973-982.
http://dx.doi.org/10.1002/gps.1389 [5] Hitchcock, N.P., Williams, J., Unützer, J., Worchel, J., Shuko, L., Cornell, J., Katon, W., Harpole, L. and Hunkler, E. (2004) Depression and Comorbid Illness in Elderly Primary Care Patients: Impact on Multiple Domains of Health Status and Well-Being. Annals of Family Medicine, 2, 555-562.
http://dx.doi.org/10.1370/afm.143 [6] Callahan, C. (2001) Quality Improvement Research on Late Life Depression in Primary Care. Medical Care, 39, 722-784.
http://dx.doi.org/10.1097/00005650-200108000-00004 [7] Djernes, J.K. (2006) Prevalence and Predictors of Depression in Populations of Elderly: A Review. Acta Psychiatrica Scandinavia, 113, 372-387.
http://dx.doi.org/10.1111/j.1600-0447.2006.00770.x [8] Robinson, W.D., Bischoff, R., Geske, J. Backer, E., Olson, M., Jarzynka, K. and Swinton, J. (2012) Rural Experiences with Mental Illness: Through the Eyes of Patients and their Families. Families, Systems, & Health, 30, 308-321.
http://dx.doi.org/10.1037/a0030171 [9] Holm, A.L., Lyberg, A. and Severinsson, E. (2014) Living with Stigma: Depressed Elderly Persons’ Experiences of Physical Health Problems. Nursing Research and Practice, 2014, Article ID: 527920.
http://dx.doi.org/10.1155/2014/527920 [10] Zeng, W., North, N. and Kent, B. (2012) A Framework to Understand Depression among Older Persons. Journal of Clinical Nursing, 21, 2399-2409.
http://dx.doi.org/10.1111/j.1365-2702.2011.04049.x [11] Allan, J. and Dixon, A. (2009) Older Women’s Experiences of Depression: A Hermeneutic Phenomenological Study. Journal of Psychiatric and Mental Health Nursing, 16, 865-873.
http://dx.doi.org/10.1111/j.1365-2850.2009.01465.x [12] Lyberg, A., Holm, A.L., Lassenius, E., Berggren, I. and Severinsson, E. (2013) Older Persons’ Experiences of Depressive Ill-Health and Family Support. Nursing Research & Practice, 2013, Article ID: 837529.
http://dx.doi.org/10.1155/2013/837529 [13] Chew-Graham, C., Kovandzic, M., Gask, L., Burroughs, H., Clarke, P., Sanderson, H. and Dowrick, C. (2012) Why May Older People with Depression Not Present to Primary Care? Messages from Secondary Analysis of Qualitative Data. Health & Social Care in the Community, 20, 52-60.
http://dx.doi.org/10.1111/j.1365-2524.2011.01015.x [14] Fixsen, D.L., Blasé, K.A., Naoom, S.F. and Wallace, F. (2009) Core Implementation Components. Research on Social Work Practice, 19, 531-540.
http://dx.doi.org/10.1177/1049731509335549 [15] World Health Organization (2008) Caring for People with Chronic Conditions: A Health System Perspective.
http://apps.who.int/iris/bitstream/10665/112830/1/9789241506793_eng.pdf?ua=1 [16] Bodenheimer, T., Wagner, E.H. and Grumbach, K. (2002) Improving Primary Care for Patients with Chronic Illness. The Chronic Care Model. The Journal of the American Medical Association, 288, 1775-1779.
http://dx.doi.org/10.1001/jama.288.14.1775 [17] Bodenheimer, T., Wagner, E.H. and Grumbach, K. (2002) Improving Primary Care for Patients with Chronic Illness. The Chronic Care Model, Part 2. The Journal of the American Medical Association, 288, 1909-1914.
http://dx.doi.org/10.1001/jama.288.15.1909 [18] Wagner, E.H., Glasgow, R.E., Davis, C., Bonomi, A.E., Lloyd, P., McCulloch, D., Carver, P. and Sixta, C. (2001) Quality Improvement in Chronic Illness Care: A Collaborative Approach. Joint Commission Journal on Quality Improvement, 27, 63-80. [19] Holm, A.L., Lyberg, A., Lassenius, E., Berggren, I. and Severinsson, E. (2013) Older Persons’ Lived Experiences of Depression and Self-Management. Issues in Mental Health Nursing, 34, 757-764.
http://dx.doi.org/10.3109/01612840.2013.809829 [20] Holm, A.L., Lyberg, A., Berggren, I., Cutcliffe, J. and Severinsson, E. (2014) Shadows from the Past—The Situated Meanings of Being Suicidal among Depressed Older People Living in the Community. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 35, 253-260.
http://dx.doi.org/10.1027/0227-5910/a000259 [21] Holm, A.L. and Severinsson, E. (2014) Surviving Depressive Ill-Health: A Qualitative Systematic Review of Older Person’s Narratives. Nursing & Health Sciences, 16, 131-140.
http://dx.doi.org/10.1111/nhs.12071 [22] Holm, A.L. and Severinsson, E. (2013) Interdisciplinary Team Collaboration during Discharge of Depressed Older Persons: A Norwegian Qualitative Implementation Study. Nursing Research and Practice, 2013, Article ID: 794743.
http://dx.doi.org/10.1155/2013/794743 [23] Holm, A.L. and Severinsson, E. (2014) Perceptions of the Need for Improvements in Healthcare after Implementation of the Chronic Care Model. Nursing & Health Sciences, 16, 442-448.
http://dx.doi.org/10.1111/nhs.12136 [24] Severinsson, E. and Holm, A.L. (2014) Chronic Disease Management: Implementation and Coordination of Healthcare Systems for Depressed Elderly Persons. Issues in Mental Health Nursing, 35, 934-939.
http://dx.doi.org/10.3109/01612840.2014.930215 [25] Holm, A.L., Lyberg, A., Berggren, I., Åström, S. and Severinsson, E. (2014) Social Capital and Depressive Ill Health—An Evaluative Approach to the Implementation of the Chronic Care Model. Open Journal of Nursing, 4, 683-694.
http://dx.doi.org/10.4236/ojn.2014.410073 [26] Holm, A.L., Lyberg, A., Berggren, I. and Severinsson, E. (2014) Shared Decision-Making after Implementation of the Chronic Care Model (CCM)—An Evaluative Approach. Open Journal of Nursing, 4, 824-835.
http://dx.doi.org/10.4236/ojn.2014.412088 [27] Severinsson, E. and Holm, A.L. (2014) Understanding and Improving Quality of Care in the Context of Depressed Elderly Persons Living in Norway. Open Journal of Nursing, 4, 809-817.
http://dx.doi.org/10.4236/ojn.2014.412086 [28] Polit, D.F. and Beck, C.T. (2012) Nursing Research: Generating and Assessing Evidence for Nursing Practice. Lippincott Williams & Wilkins, London. [29] Hsieh, H.F. and Shannon, S.E. (2005) Three Approaches to Qualitative Content Analysis. Qualitative Health Research, 15, 1277-1288. [30] Graneheim, U.H. and Lundman, B. (2004) Qualitative Content Analysis in Nursing Research: Concepts, Procedures and Measures to Achieve Trustworthiness. Nurse Education Today, 24, 105-112.
http://dx.doi.org/10.1016/j.nedt.2003.10.001 [31] Sandelowski, M. and Leeman, J. (2011) Writing Usable Qualitative Health Research Findings. Qualitative Health Research, 22, 1404-1413.
http://dx.doi.org/10.1177/1049732312450368 [32] Denzin, N.K. and Lincoln, Y.S. (2008) Collecting and Interpreting Qualitative Materials. Sage, Los Angeles. [33] Elo, S., Käriänen, M., Kanste, O., Pölkki, T., Utriainen, K. and Kyngärs, H. (2014) Qualitative Content Analysis: A Focus on Trustworthiness. SAGE Open, 4, 1-10.
http://dx.doi.org/10.1177/2158244014522633 [34] World Medical Association (2014)
http://www.wma.net/en/30publications/10policies/b3/ [35] Liamputtong, P. (2007) Researching the Vulnerable: A Guide to Sensitive Research Methods. Sage Publisher, London. [36] Laister, S. (2011) Older Adults’ Perceptions of Feeling Safe in an Intensive Unit. Journal of Advanced Nursing, 67, 2649-2657.
http://dx.doi.org/10.1111/j.1365-2648.2011.05714.x [37] The Norwegian Social and Health Department (1997-1998) Stortingsproposisjon No. 63: Opptrappingsplan for psykisk helse 1999-2009. Sosial og Helsedepartementet, Oslo. [38] The Norwegian Research Council (2009) Evaluering av opptrappingsplanen for psykisk helse (2001-2009). Sluttrapportsyntese og analyse av evalueringens delprosjekter. [39] Ahlström, B.H., Skärsäter, I. and Danielsson, E. (2009) Living with Major Depression: Experiences from Families’ Perspectives. Scandinavian Journal of Caring Sciences, 23, 309-316.
http://dx.doi.org/10.1111/j.1471-6712.2008.00624.x [40] Coleman, K., Austin, B.T., Brach, C. and Wagner, E.H. (2009) Evidence on the Chronic Care Model in the New Millennium. Health Affairs, 28, 75-85.
http://dx.doi.org/10.1377/hlthaff.28.1.75 [41] Dorr, D.A., Wilcox, A., Burns, L., Brunker, C.P., Narus, S.P. and Clayton, P.D. (2006) Implementing a Multidisease Chronic Care Model in Primary Care Using People and Technology. Disease Management, 9, 1-15.
http://dx.doi.org/10.1089/dis.2006.9.1 [42] Solberg, L.I., Crain, A.L., Sperl-Hillen, J.M., Hroscikoski, M.C., Engebretson, K.I. and O’Connor, P.J. (2006) Care Quality and Implementation of the Chronic Care Model: A Quantitative Study. Annals of Family Medicine, 4, 310-316. http://dx.doi.org/10.1370/afm.571 [43] Kadu, M.K. and Stolee, P. (2015) Facilitators and Barriers of Implementing the Chronic Care Model in Primary Care: A Systematic Review. BMC Family Practice, 16, 12.
http://dx.doi.org/10.1186/s12875-014-0219-0 [44] Holm, A.L. and Severinsson, E. (2012) Chronic Care Model for the Management of Depression: Synthesis of Barriers to, and Facilitators of Success. International Journal of Mental Health Nursing, 21, 513-523.
http://dx.doi.org/10.1111/j.1447-0349.2012.00827.x [45] Craig, P., Macintyre, S., Michie, S., Nazareth, I. and Petticrew, M. (2008) Developing and Evaluating Complex Interventions: The New Medical Research Council Guidance. British Medical Journal, 337, a1655.