Development of Virtual Mental Health Stepped Care Service for a Heart Failure Remote Management Program: Qualitative Study (Preprint)

BACKGROUND Depression is highly prevalent yet undertreated among people living with heart failure (PLWHF), indicating barriers to mental health services. Although various digital mental health interventions have been developed to detect, treat, and manage depression among PLWHF, these interventions have seen limited integration into clinical care and a lack of implementation research. Stepped care is a service innovation that may promote the implementation of these technologies into clinical settings, but few studies have examined how these services are designed in clinical settings. OBJECTIVE To identify strategies to address health system barriers to accessing mental health care from the perspective of PLWHF, clinicians, and researchers, and to incorporate these strategies into the design of a virtual mental health stepped care service within a heart failure remote management program. METHODS A qualitative description study was conducted involving purposive recruitment of PLWHF, clinicians, and researchers from a heart failure remote patient management program. As part of a service design approach, semi-structured interviews were conducted to explore potential strategies to address barriers to accessing mental health services. Two researchers coded the data descriptively and constructed themes to guide the development of a virtual stepped care service. RESULTS A total of 22 participants were interviewed, comprising 13 PLWHF and 9 clinicians and researchers. Six themes were identified, four of which were requirements and two were foundational principles of the virtual stepped care service. The four requirements were to 1) adopt a collective approach to identify signals of distress, wherein distress could be detected through multiple methods, people, and times in the care journey; 2) maintain a referral-based approach; 3) rely on existing mental health human resources; and 4) offer PLWHF the ability to choose among various mental health care options. These requirements were thought to exist within a service based on two foundational principles: 1) building on organizational strengths and 2) reducing treatment burden. Based on these requirements and principles, a virtual stepped care service was developed, incorporating a depression screening module, referral-based workflows, and where clinically appropriate, patient choice in treatment selection. CONCLUSIONS The stakeholder-informed design of the virtual stepped care service contributes to the broader, though still limited, literature on the design of stepped care services and offers an example of how these service delivery models can be tailored to their intended contexts. Although each component of the resultant virtual stepped care service was designed to address health system barriers to mental health care for PLWHF, resource limitations may constrain the strategies possible in order to balance the needs of the health system (feasibility) and the needs of individual clinical care (quality of care). Future research should evaluate the acceptability of the design service delivery model from the perspective of PLWHF and clinicians.