TeamCare: A Collaborative Team Care Model

Depression or depressive symptoms are common in people with diabetes and are present in approximately 15% of patients with diabetes, rates that are about 30% higher compared to the general population.  Depressive disorders in people with diabetes are associated with poorer self-care behaviors, poorer glycemic control, health complications, decreased quality of life and psychological well-being, increased family problems, and higher health care costs.

A recent systematic review completed by our research group showed that a nurse case manager working in a collaborative team care model with a family physician and psychiatrist provides a significant improvement in depression in patients with diabetes.    In order to address other measures of disease control, the ABCD project will expand the intervention to address depression first but to also include other areas of diabetes management.  The intervention will contain 3 phases of treatment: Phase 1) interventions to improve depression symptoms, then phase 2) will  focus on disease control of blood sugar, blood pressure or cholesterol, and phase 3) will provide an emphasis on improving lifestyle behaviors such as healthy eating, physical activity or smoking cessation.

We are proposing a collaborative team care model which involves a Registered Nurse acting as case manager providing active patient management under the supervision of a family physician and consulting psychiatrists and internists.   The case manager has weekly supervisory meetings with the psychiatrist, internist and/or family physician to review new patients and patient progress. The case managers will be initially trained through a standardized program on behavioral activation therapies and medication management.  In practice, they would provide recommendations for change in treatment plan according to evidence-based algorithms and expert supervision and then support implementation of a new care plan.   The nurse case manager will also partner with the patient to develop a shared definition of problems, provide education and support, agree on specific targets/goals and individualized action plan, offer support and problem solving to optimize self-management, and closely monitor any treatment adherence and outcomes.

The primary outcome will be depression remission measured by the PHQ-9 survey, medication use and behavioral therapy. Secondary outcomes will look at cardio-metabolic changes including blood pressure, lipid and A1C reduction and use of medications.


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