Stepped Care: A Method to Deliver Increased Access to Psychological Therapies

Abstract

Objective: To introduce stepped care as a method of organizing the delivery of treatments, and to consider the factors necessary for implementation.Method: Stepped care is described within the context of strategies such as collaborative care that aim to increase access to mental health care through the improved coordination of care between primary and specialist mental health services. Results from the implementation of stepped care in the United Kingdom and elsewhere are used to highlight the factors required for introducing stepped care into routine services. Issues to address when implementing highvolume services for common mental health problems are derived from this experience. Results:Stepped care sits within the continuum of organizational systems, from situations where responsibility rests almost entirely with primary care clinicians to systems where all patients are managed by specialists for the entire duration of their treatment. Its core principles of delivering low-burden treatments first, followed by careful patient progress monitoring to step patients up to more intensive treatment, are easy to articulate but lead to considerable implementation diversity when services attempt to work in this manner. Services need to ensure they have specific staff competency training, including skills in delivering evidencebased treatments, access to telephony, and smart patient management informatics systems. Conclusions:Stepped care can provide the delivery system for supported self-management. To be successful, health systems need high levels of clinical outcome data and appropriately trained workers. Further attention is required to ensure equity of access and to reduce patient attrition in these systems. W W WObjectif : Présenter les soins en étapes comme méthode d'organisation de la prestation des traitements, et envisager les facteurs nécessaires pour la mettre en oeuvre.Méthode : Les soins en étapes sont décrits dans le contexte de stratégies comme les soins en collaboration qui visent à améliorer l'accès aux soins de santé mentale par une meilleure coordination des soins entre les soins de première ligne et les services des spécialistes en santé mentale. Les résultats de la mise en oeuvre des soins en étapes au Royaume-Uni et ailleurs servent à mettre en évidence les facteurs nécessaires à l'introduction des soins en étapes dans les services réguliers. Les questions quant au moment de mettre en oeuvre des services ayant un grand nombre de patients avec des problèmes de santé mentale courants sont tirées de cette expérience.Résultats : Les soins en étapes s'inscrivent dans le continuum des systèmes organisationnels, qu'il s'agisse de situations où la responsabilité incombe presque entièrement aux cliniciens des soins de première ligne ou de systèmes où tous les patients sont pris en charge par des spécialistes pour toute la durée du traitement. Ses principes fondamentaux consistant à dispenser d'abord des traitements faciles à mettre en oeuvre, puis à surveiller soigneusement les progrès des patients pour ...

The Efficacy of Mindfulness-Based Interventions in Primary Care: A Meta-Analytic Review

“…4,5 In the trials included in this meta-analysis, the contents of MBI programs were not adapted to primary care patients' local needs, culture, or epidemiology; thus, future protocols should include this framework. Another key component when implementing primary care interventions is the stepped-care approach, 14,50 but none of the trials addressed this issue, probably because of the uniformly strict adherence to the manual for MBI programs. On the other hand, when considering the implementation of complex interventions in primary care, professionals and researchers should be more flexible in adapting protocols to the context of this setting within the health system, for example, by using shorter protocols or self-help online interventions.…”

The implementation of mindfulness in healthcare systems: a theoretical analysis

“…"Stepped-care" and "low intensity-high volume": key concepts for the large-scale implementation of mindfulness When we discuss the implementation of MBIs in healthcare systems, we consider high-volume interventions. A large-scale strategic implementation plan for mindfulness may benefit from concepts such as "stepped-care" and "low intensity-high volume" interventions [22][23][24], thereby making the models of these types of MBIs more flexible and increasing access to MBIs.…”

“…In other words, there is an access barrier to therapies, mainly related to the lack of professional skills needed to provide them [22][23][24]. A useful strategy would be the "stepped-care" model, which consists of offering the same interventions (trying to keep the same theoretical models and practices normally offered) in increasing levels (steps) of intensity, according to the needs of patients, and maximizing healthcare system resources.…”

“…In this case, introductory mindfulness groups could be offered on a large scale and, following a model with increasing intensity and complexity (in steps), could offer classic models of MBIs, such as MBSR and MBCT, in the most advanced group. This is a theoretical and speculative model; therefore, the same principles applied to all therapies should be followed: quality, safety, patient acceptability, clinical effectiveness, cost effectiveness and efficiency (understood here as having clinical results at least equal to other intervention models, but with lower costs) [22][23][24].…”

And Now for Something Completely Different… Self-Management

“…3,4 Improving access to screening, evidence-based intervention, and self-management for mild-to-moderate mental health problems may be the game-changer that improves accessibility and outcomes for many of the people living with mental illness who are not currently getting the mental health services they need and could benefit from. Enjoy the read, and think about and act on the ideas.…”