Table 1

Plan-Do-Study-Act cycles of change during implementation

Primary care confusion on how to link patients with correct behavioural health provider as evidenced by inappropriate referrals.Reorganise ordering from type of provider (PhD, LICSW, MD) to type of service (diagnostic evaluation, medication management, therapy).Rollout of new electronic ordering.Frequency of inappropriate referrals went down overall except for those from a few individual providers.One-on-one assistance on the new ordering system offered to those slow to adapt to new system.
Include all referrals from primary care or only those with significant symptoms warranting this intervention?Initially accepted all referrals regardless of symptom severity to help develop the programme.Data entry on initial 57 patients to explore outcomes regardless of initial severity on GAD-7.Review of initial 57 patient outcomes demonstrated difficulty in justifying treatment on subthreshold (GAD-7 <10) patients.Full course of CALM offered only to those with GAD-7 score of 10 or more. Very brief1–3 session developed and offered to others.
Therapist documentation oriented around billing requirements and not around tracking of outcomes.Registry developed and therapists given task of data entry into registry during or just after therapy visitsTrained therapy staff on web-based registry.Significant missing data as therapists reported time constraints and lack of clarity on reasons for this aspect of the model.Simplified documentation and created routine review of data in case reviews with psychologist, which improved both data entry completeness and allowed for case-based teaching.
Reference RCT CALM model also included an algorithm for medication management of anxiety.Offer medication review for patients with anxiety as a part of parallel adult care coordination available in primary care settings.Algorithm created and reviewed, option for medication review advertised.Referral rates by primary care very low for routine review of medications.Abandoned routine algorithm for anxiety medications in favour of individual consultation as needed.
  • CALM, Coordinated Anxiety Learning and Management; GAD-7, Generalized Anxiety Disorder 7 Item scale; LICSW, licensed social worker; RCT, randomised controlled trial.