Chronic Disease Management- Implementation and Coordination of Health Care Systems for Depressed Elderly People, 2013

One of the greatest challenges faced by health care systems is the increasing burden of chronic diseases. Chronic disease management is a systematic approach to the coordination of health care interventions and communication at individual, organizational, regional and national level. Primary health care and community care are important settings for the prevention of mental health problems among elderly persons living in the community. An innovative approach to user involvement and evidenced-based care for depressed elderly persons was employed in this project. Phase 1 of the project was based on a qualitative approach, phase 2 consisted of implementation of the CCM in interdisciplinary teams working in mental health clinics and community health care; and phase 3 was to evaluate the outcomes of the implemented model as well as the patients' and family members' experiences of the care provided as well as those of the interdisciplinary teams. The research questions were: 1. What are the patient's subjective experiences of his/her mental health problems? 2. What are the patient's and family members' subjective experience of health care services? 3. How can chronic disease management for persons with depression be improved? 4. How can strategies to support patients' self-management of illness be improved? 5. What do the patients' pathways through the health care system look like? Five senior researchers and one postdoctoral student from four academic disciplines (public health, nursing, social science and education) collaborated in this research.

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