Developing a shared individualized care plan |
• Collecting a patient’s biopsychosocial semi-structured history of MDD and chronic illness (diagnoses, treatments, and complications) from different perspectives (psychiatric, medical, psychological, and nursing) |
• Understanding and sharing the patient’s explanatory model of the disease |
• Negotiating the therapeutic alliance and identifying goals together with the patient from each perspective |
• Sharing decision making processes within the team |
• Explaining all the treatments to the patient in phases as an integrated process |
• Sharing the information and relevant events within the team and defining a case manager responsible for keeping the team and the patient updated |
Systematic monitoring of the care plan |
• Tracking the patient’s relevant clinical data in an electronic medical record accessible to the team members |
• Discussing progress, caseload, and resistance encountered by the patient in team supervisions |
• Assessing the patient’s needs and identifying new professionals, roles, and resources outside of the team required to meet them |
Support of the patient self-care |
• Providing tailored educational materials from each perspective to the patient |
• Fostering the patient’s motivation to get better as a shared message |
• Monitoring and promoting the patient’s adherence to the treatments and prescriptions mutually |
Team training |
• Organizing face-to-face training sessions to consolidate interprofessional collaboration ties and to develop a common language within the team |
• Encouraging the expression of needs, doubts, disagreement within the team |
• Planning scheduled training update sessions based on challenges and success |