Table 4 Rapid cycle, expert stakeholder adaptations to the DepCare multi-level implementation strategy to promote collaborative care sustainability

Functionality (usability, understandability) (perceived effectiveness, efficiency, and “ease- or lack-of-ease of use; information is comprehendible)

1. Lessen cognitive load of Preference report (e.g., use icons, pictures, pictograms, and colors give clear treatment support) (capability) – ID Team

2. Create onboarding video (more accessible than Grand Rounds meeting) (opportunity, capability, motivation) – ID Team

1. Effective patient activation language

"It's up to you" is too difficult for a depressed patient..[change to] ‘your doctor is ready to hear from you, all you need to do is click here’ " (Motivation) – Advisory Board

2. Flexible operability/delivery (e.g., for those poor access to internet/devices provide devices in clinic; phone formatting, paper copy/brochure to write appointment reminders/goals) (opportunity/practice setting, capability, motivation) Advisory Board, Core Team

3. Use low literacy screeners, use voiceover (e.g., PHQ 9) (capability) – ID team

Practice setting

• Social determinants of health screening mandates (e.g., with iPad and navigators in the waiting room)

• Electronic health record transitions to EPIC with need to align registries

• Mental health provider/care managers turnover, 1 care manager covering multiple clinics

• Inappropriate referrals to CC worsen “Providers using CC as walk-in mental health clinic…Not their purpose & not everyone is guaranteed treatment…Providers too comfortable sending all patients to CC; not asking about depression, treatment in assessments resulting in inappropriate referrals ….CC still getting referrals when patients just need to have their medication titrated, should by handled by PCP”

• Depression screening done with e-check in process

Ecological system

• Office of Mental Health includes collaborative care reimbursement codes for anxiety (not just depressed patients)

• Depression Screening becomes accountable care organization metric of interest in health care system (need to provide clinics with depression screening support, staff education)

Practice setting and ecological system

• Suicide screening mandates

• Due to COVID-19, remotely delivered collaborative care leads to improvement in show rates but inappropriate referrals (need to focus on referral and depression treatment optimization not just initiation)

Content and usefulness

(extent the tool and content/information provided by it) is perceived as helpful during clinical decision-making and care delivery)

3. Add depression/suicide screening video for staff (improve quality of screening in telemedicine era) (capability) – ID Team

4. Address post-COVID-19 barriers in problem solving meetings (transition from billing/start up barriers with CC to telepsychiatry, leveraging EPIC, remote delivery, identifying champions) (opportunity/Practice setting and Ecological System, capability) – ID Team, Advisory Board

5. Adapt provider education to include motivational messaging, onboarding (not just CC initiation/referral but triage, optimization, appropriate referrals, how to use DepCare tool) (capability, motivation, opportunity) – ID team

6. Summary report to focus on treatment optimization/medication support (opportunity/Practice setting, capability) –Advisory Board

7. Add Job Aid and EPIC Smart phrase: to support appropriate referral, decisional support (capability) – ID Team

4. Patient activation/Education/Goal Setting (less so on shared decision making, selecting options)

“Messaging should include language about – things can be different. You are taking a step to do something today. Even though this is scary, this could be the start of getting your life back. We're happy to be partners in your care”, “overall goal to get you to a care manager” (motivation, capability) – ID team, Advisory Board, Creative Team

5. Triage/personalize experience (based on history/treatment/severity, include atypical symptoms link anger/pain, options to defer treatment)

“messaging should emphasize that there’s no one correct model of treatment, that each person’s treatment is tailored to fit their needs.” (motivation, opportunity/Practice setting, capability) – Creative Team, Advisory Board, Intervention Team

6. Add content hub (links to suicide, wellness, and depression treatment resources and hotlines) (opportunity/ecological system/practice setting, capability) – Advisory Board

7. Add patient story (psychoeducation, activation, cultural tailoring) (motivation, capability)

8. Include anxiety/suicide screening (Opportunity/practice setting and ecological system) Advisory Board, ID team

Visibility, workflow, and navigation

(extent to which noticed or attended; general order/sequence of tasks and activities in patient encounter; ability to move through the system)

8. Screening support/align with clinic initiatives (e.g., include suicide screening, provide depression screening support if setting not screening, leverage screening results if clinic screening; provide quality improvement depression screening education video) (Opportunity/Practice Setting, motivation, capability) – Core Team, Advisory Board

9. Electronic preference report (paper copy in person EPIC message to both PCP and care manager, email) (Opportunity) – ID Team

10. Option to bypass provider Ensure care managers receive tool results “infeasible to have a self-referral option because of the influx of patients” (opportunity/Practice setting, capability, motivation) – ID Team

9. Flexible delivery. Medical assistants deliver to all PHQ2 positive patients options for waiting room admin with staff vs. text/email at home, bypass PHQ if already done by clinic (opportunity/practice setting) – Advisory Board, ID Team