Scaling the collaborative care model in obstetrics: Multilevel determinants to guide implementation

The Collaborative Care Model (CCM) is an evidence-based approach to care that improves health outcomes in primary care settings by integrating mental health into routine medical care. While recent adaptations have tailored the CCM for use in obstetric settings to address perinatal mental health (PMH) concerns, real-world implementation remains limited. Bridging this gap between research and practice requires an understanding of contextual factors influencing adoption and sustainment. As a sub-study of the Collaborative Care Model for Perinatal Wellness Support Services-Population-Level Upstream Systems Change (COMPASS+) Randomized Trial, our objective was to identify key factors modifying the implementation of the perinatal CCM (pCCM).

We conducted a qualitative implementation study guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to evaluate facilitators and barriers of pCCM implementation during the Preparation phase of pre-implementation. Using purposive sampling, we recruited clinical and administrative key informants from five obstetric clinics and one birthing hospital, all affiliated with COMPASS+ Trial. Semi-structured interviews were designed to elicit determinants at multiple contextual levels. Data were analyzed using the Rapid Qualitative Analysis process. Coding and thematic analysis were guided by the EPIS domains-inner context, outer context, bridging factors, and innovation characteristics.

A total of 20 individuals were interviewed prior to thematic saturation. Determinants influencing adoption and sustainability of the pCCM were mapped across EPIS domains. Several cross-cutting barriers emerged on the clinic level related to limited office space and workflow changes to accommodate the pCCM, at the population level including societal stigma regarding the use of psychotropic medications during pregnancy, and among bridging factors such as need for mental health referral networks. Participants also identified multiple facilitators that support integration of the CCM into obstetric settings, such as increased medical touchpoints during pregnancy, staff and leadership buy-in, and preexisting comfort with obstetric clinicians. The need for site-level adaptation was an underlying theme, underscoring the opportunity to tailor implementation strategies to local contexts.

The CCM is well suited to obstetric care but requires context-specific adaptation to support adoption and sustainability. Implementation strategies must address multilevel barriers and leverage existing facilitators to bridge the gap between research and practice.