In order to deliver effective care, it is necessary to organise interdisciplinary activities for older persons who suffer from depressive disorders. This paper evaluated the interdisciplinary team members’ perceptions of cooperation in the discharge planning of depressed older persons based on the Chronic Care Model (CCM). A qualitative implementation design was used, data were collected by means of multistage focus groups, and a thematic analysis was performed. Three themes emerged: lack of effective team leadership in the community, the need to change the delivery system, and enhancing self-management support for depressed older persons as well as the participation of their families. It was concluded that nurse managers must find ways of supporting the depressed older persons by better structuring the care, increasing cooperation with organisational leadership, and creating an environment characterised by trust and mutual respect. Distrust can have serious implications for discharge planning collaboration. The development of a common vision of transparency in the organization is important as is a policy of change among leadership and in clinical practice. 1. Introduction Depression in older persons is an increasingly complex health problem due to the difficulties involved in distinguishing it from symptoms of physical ill-health, dementia, normal aging, and grief [1, 2]. Older persons with depression are a vulnerable group for whom the transition from hospital to community care is of critical importance. Evidence has demonstrated that effective and safe interventions, delivered in collaboration between hospital and community care, are associated with a reduced rate of readmission [3]. Naylor et al. [4] identified nine interventions that demonstrated positive effects related to hospital readmission, thus constituting a key focus of health reform. According to Choi and Pak [5], interdisciplinary analysis synthesises and harmonises disciplines into a coordinated and coherent whole. Collaboration begins when different disciplines meet to share each other’s knowledge [6]. Every health care professional possesses evidence-based knowledge, that is, of value to the other members of the team [7]. Interest in implementation issues has increased in the health services field in recent decades and can be related to the development of Evidence Based Practice (EBP) and programmes as well as the concern that people will not benefit unless EBP interventions and programmes are correctly implemented [8]. EBP requires that “decisions about healthcare are based on the
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