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Team-Based Medical Care Shows Better Patient Outcomes

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Researchers at the University of Washington and Group Health Research Institute, both in Seattle, tested a primary care intervention where nurses worked with patients and health teams to manage care for depression and physical disease together, using evidence-based guidelines. The results from this randomized controlled trial showed for patients less depression; better control of blood sugar, blood pressure and cholesterol; and improved quality of life.

Depression is common in patients with diabetes and heart disease, and it has been linked to worse self-management and more complications and deaths. Depression can make people feel helpless and hopeless about managing other chronic diseases. In turn, coping with chronic disease can worsen depression. This tangle of health problems can feel overwhelming—for patients, their families and their health care providers.

The trial involved 214 Group Health Cooperative patients who were randomly assigned to either standard care or TEAMcare, as the new intervention is called. In the TEAMcare intervention, a nurse care manager coached each patient, monitored disease control and depression, and worked with the patient’s primary care doctors to make changes in medications and lifestyle when treatment goals were not reached. Working together, the nurse and patient set step-by-step goals: reductions in depression and blood sugar, pressure and cholesterol levels. Patients assigned to the standard care arm of the study did not receive the nurses’ coaching and monitoring services.

To reach these goals, the nurse regularly monitored the patient’s mental and physical health. Based on guidelines that promoted incremental improvements, the care team offered recommendations to the patient’s primary care doctor to consider changes to the dose or type of medication used for managing blood pressure, blood sugar, lipids or depression. This process is called “treating to target,” which helped boost patients’ confidence as goals were accomplished.

After one one year — compared with the standard care control group — patients with the TEAMcare intervention were significantly less depressed and also had improved levels of blood glucose, low-density lipoprotein (LDL) cholesterol, and systolic blood pressure. These measures have been linked to higher risks of complications and deaths from diabetes and heart disease.

TEAMcare intervention patients also reported enhanced quality of life and satisfaction with care for depression and either diabetes, heart disease or both. Patients were more likely to have timely adjustment of glucose levels, high blood pressure, cholesterol, and antidepressant medications.

In preliminary calculations, the two-year TEAMcare intervention cost is estimated at $1,224 per patient. For each of these patients, medical care costs run about $10,000 per year for their health care systems. The findings are published in the 30 December 2010 New England Journal of Medicine (paid subscription required).

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