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Table 1 Description of collaborative care components included in the PARTNERS model

From: Refining a model of collaborative care for people with a diagnosis of bipolar, schizophrenia or other psychoses in England: a qualitative formative evaluation

Collaborative care component Expression in the PARTNERS model
1. An underpinning conceptual model of collaboration Wagner’s Chronic Care Model elements: protocol-based planned care, the development of case management roles, support for patient self-management, expert consultation and decision support, shared information
CHIME framework for personal recovery [11] (recovery processes to be targeted by the direct patient support component): connection, hope, identity, meaning, empowerment
2. Identification of patients: method Eligible service users identified through screening of records against inclusion criteria
3. Identification of patients: setting Primary and secondary care
4. Provider integration: Specialist mental health worker (known as a care partner) is allocated from local secondary care community mental health team and based in GP surgeries.
5.Multi-disciplinary working Care partner works alongside GPs and other primary care practitioners, under the supervision of a qualified mental health worker (from any mental health profession) based in local secondary care community mental health team, with access to consultation from psychiatrists if not available through supervision.
6. Systematic communication between providers Care partners record information in shared records, including progress notes and care plans. Co-location supports face to face communication between care partners and primary care practitioners.
7. Case management Care partners co-ordinate care, liaising with other providers (e.g. primary care practitioners, community mental health teams, community organisations) to ensure service users’ needs are met.
8. Study protocols / treatment algorithms Intervention manual, describing the principles and approaches which should be adopted by care partners while responding flexibly to individual need.
9. Systematic monitoring / follow up Regular review of service users at individually negotiated intervals, varying in intensity according to need, with a minimum of telephone contact three times a year and an expectation of more frequent face to face contact as standard. Routine use of standardised measures to monitor mental health.
10. Pharmacological intervention No specific intervention, unless identified as a personal goal by the service user, leading to the development of individual action plans, which could include psychiatric review.
11. Psychological intervention Care partner provides coaching to enable the service user to identify personally meaningful goals, individualised action plans and relevant resources and to become an active participant in managing their own health and wellbeing.
12. Education for mental health / primary care providers Two-day training in the intervention as described in the manual provided to care partners and supervisors.
13. Patient education / promoting self-management Care partner provides information and uses motivational interviewing approaches to encourage service user to identify and work towards personal goals related to improved physical health and mental wellbeing.
14. Shared decision making with patients Care partner adopts a collaborative style of interaction with service users, engaging with them as an equal in the service of the aim of achieving service user empowerment, as specified by the CHIME framework.