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Intervention Summary

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TEAMcare

TEAMcare was developed to enhance the quality of mental and physical health care for adult patients with comorbid depression and poorly controlled diabetes and/or coronary heart disease. The intervention aims to combine support for patients through self-care with pharmacotherapy to manage depression and improve glycemic, blood pressure, and lipid control by integrating a treat-to-target program for diabetes and coronary heart disease with collaborative care for depression. TEAMcare involves a team approach to establishing individualized clinical and self-care goals, whereby the patient works collaboratively with a registered nurse who manages the patient's care under the supervision of a primary care physician (but not the patient's primary care physician) and a psychiatrist.

During a structured visit at the patient's primary care clinic every 2-3 weeks, the nurse uses motivational and encouraging coaching to help the patient address his or her health problems and set goals for improved adherence to medication, diet, and exercise regimens and improved self-care (e.g., self-monitoring of blood pressure and glucose levels). The nurse tracks the patient's medication adherence, depression symptoms, and laboratory and clinical values of glycated hemoglobin (HbA1c), systolic blood pressure, and low-density lipoprotein cholesterol (LDL-C). The nurse meets with the physician supervisors once a week (i.e., primary care physician and psychiatrist) to review each patient's case and discuss recommendations for medication adjustments, which are provided to the patient's primary care physician, who writes prescriptions. These weekly systematic case reviews enhance care coordination and help ensure accountability through the team-based follow-up to guideline-level disease management and achievement of clinical goals. Once a patient has achieved targeted levels for relevant measures, the nurse and patient develop a maintenance plan that includes stress reduction, behavioral goals, continued use of medications, and identification of symptoms associated with worsening depression and glycemic control. The nurse continues to follow up with the patient by telephone every 4-6 weeks.

Each patient receives approximately 10 in-person contacts, as well as 10 telephone contacts with the nurse over a 12-month period. The patient's clinic also can choose to provide each patient with self-care materials, including the Depression Helpbook, materials on chronic disease management, and self-monitoring devices (e.g., blood pressure monitor, blood glucose meter) appropriate to the patient's condition.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: October 2013
1: Depression and physical health
2: Depression
3: Medication adjustment
4: Social role disability
5: Cost-effectiveness
Outcome Categories Employment
Family/relationships
Mental health
Quality of life
Social functioning
Ages 26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Race/ethnicity unspecified
Settings Outpatient
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History TEAMcare was first implemented in September 2010. Since then, 11 institutions have implemented TEAMcare in California, Colorado, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Texas, Washington, and Wisconsin and in Alberta, Canada. Approximately 4,000 individuals have received the intervention.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: October 2013

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Katon, W. J., Lin, E. H. B., Von Korff, M., Ciechanowski, P., Ludman, E. J., Young, B., et al. (2010). Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine, 363(27), 2611-2620.  Pub Med icon

Katon, W., Russo, J., Lin, E. H. B., Schmittdiel, J., Ciechanowski, P., Ludman, E., et al. (2012). Cost-effectiveness of a multicondition collaborative care intervention: A randomized controlled trial. Archives of General Psychiatry, 69(5), 506-514.  Pub Med icon

Lin, E. H. B., Von Korff, M., Ciechanowski, P., Peterson, D., Ludman, E. J., Rutter, C. M., et al. (2012). Treatment adjustment and medication adherence for complex patients with diabetes, heart disease, and depression: A randomized controlled trial. Annals of Family Medicine, 10(1), 6-14.  Pub Med icon

Von Korff, M., Katon, W. J., Lin, E. H. B., Ciechanowski, P., Peterson, D., Ludman, E. J., et al. (2011). Functional outcomes of multi-condition collaborative care and successful ageing: Results of randomised trial. BMJ (British Medical Journal), 343, d6612.  Pub Med icon

Outcomes

Outcome 1: Depression and physical health
Description of Measures Depression and physical health were assessed as a composite outcome by using a multivariate model to describe the results of the following four measures over 12 months:

  • Depression, which was measured with the Symptom Checklist-20 (SCL-20) at baseline and at 6 and 12 months. The SCL-20 consists of a 13-item depression scale and 7 items intended to more completely assess criterion symptoms and improve responsiveness. Using a 5-point scale ranging from 0 (not at all) to 4 (extremely), respondents rate each item. Higher scores indicate more symptoms with greater intensity.
  • HbA1c level, which was measured at baseline and at 6 and 12 months.
  • Systolic blood pressure, which was measured at baseline and at 6 and 12 months. Blood pressure readings were taken three times after 20 minutes of rest in a sitting position, and the average of the second and third readings was used.
  • Fasting LDL-C level, which was measured at baseline and at 12 months.
Key Findings A study was conducted with patients who were recruited from primary care clinics; met certain requirements for major depression; and had diagnoses of diabetes, coronary heart disease, or both, with one or more measures of poor disease control within the previous 12 months. Patients were randomized to the intervention group or the control group, in which they received enhanced usual care. Patients in the enhanced usual care group were advised to consult with their primary care physician to receive care for depression and for diabetes, coronary heart disease, or both, and with the patients' permission, their primary care physicians received results from the measures of depression and physical health at baseline and at 6- and 12-month follow-ups. Patients who received enhanced usual care could self-refer to mental health care, or primary care physicians in their health maintenance organization plan could refer them.

From baseline to the 12-month assessment, patients in the intervention group had a greater overall improvement in the control of depression and physical health compared with patients in the control group (p < .001).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)
Outcome 2: Depression
Description of Measures Depression was measured with the Symptom Checklist-20 (SCL-20) at baseline and at 6, 12, 18, and 24 months. The SCL-20 consists of a 13-item depression scale and 7 items intended to more completely assess criterion symptoms and improve responsiveness. Using a 5-point scale ranging from 0 (not at all) to 4 (extremely), respondents rate each item. Higher scores indicate more symptoms with greater intensity.
Key Findings A study was conducted with patients who were recruited from primary care clinics; met certain requirements for major depression; and had diagnoses of diabetes, coronary heart disease, or both, with one or more measures of poor disease control within the previous 12 months. Patients were randomized to the intervention group or the control group, in which they received enhanced usual care. Patients in the enhanced usual care group were advised to consult with their primary care physician to receive care for depression and for diabetes, coronary heart disease, or both, and with the patients' permission, their primary care physicians received results from the measures of depression and physical health at baseline and at 6-, 12-, 18-, and 24-month follow-ups. Patients who received enhanced usual care could self-refer to mental health care, or primary care physicians in their health maintenance organization plan could refer them.

From baseline to the 12-month follow-up, more patients in the intervention group had a 50% or greater reduction in the SCL-20 score compared with patients in the control group (p < .001). From baseline to the 24-month follow-up, the SCL-20 score remained lower for patients in the intervention group compared with those in the control group (p < .0001).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.7 (0.0-4.0 scale)
Outcome 3: Medication adjustment
Description of Measures This outcome was assessed by examining automated prescription fill data from pharmacies for medications in five classes: (1) antihypertensive medications, (2) oral hypoglycemic medications, (3) insulin, (4) lipid-lowering medications, and (5) antidepressant medications. Medication adjustment was defined by the following changes over the 12-month study period: pharmacotherapy initiation (i.e., increase in the number of medication classes prescribed) and treatment adjustment rates (i.e., change in the daily dosage of at least one ongoing medication, switch to a medication in a different class, switch to a different medication within the same class). Higher rates of medication adjustment indicate more frequent and timely disease control efforts.
Key Findings A study was conducted with patients who were recruited from primary care clinics; met certain requirements for major depression; and had diagnoses of diabetes, coronary heart disease, or both, with one or more measures of poor disease control within the previous 12 months. Patients were randomized to the intervention group or the control group, in which they received enhanced usual care. Patients in the enhanced usual care group were advised to consult with their primary care physician to receive care for depression and for diabetes, coronary heart disease, or both, and with the patients' permission, their primary care physicians received results from the measures of depression and physical health at baseline and at 6- and 12-month follow-ups. Patients who received enhanced usual care could self-refer to mental health care, or primary care physicians in their health maintenance organization plan could refer them.

From baseline to the 12-month follow-up, the rates of medication adjustment were higher for patients in the intervention group relative to those in the control group in all medication classes:

  • For antihypertensive medications, the rate for patients in the intervention group was almost twice that for patients in the control group (relative rate [RR] = 1.86; p < .001).
  • For oral hypoglycemic medications, the rate for patients in the intervention group was almost twice that for patients in the control group (RR = 1.80; p < .05).
  • For insulin, the rate for patients in the intervention group was 3 times that for patients in the control group (RR = 2.97; p < .001).
  • For lipid-lowering medications, the rate for patients in the intervention group was more than 1.5 times that for patients in the control group (RR = 1.56; p < .05).
  • For antidepressant medications, the rate for patients in the intervention group was more than 6 times that for patients in the control group (RR = 6.20; p < .001).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)
Outcome 4: Social role disability
Description of Measures Social role disability (i.e., disability in carrying out life activities) was measured by the 3-item Sheehan Disability Scale. Using a scale ranging from 0 (not at all) to 10 (unable to carry on any activities), participants rate the extent to which their health interfered with their work, family life, and social life.
Key Findings A study was conducted with patients who were recruited from primary care clinics; met certain requirements for major depression; and had diagnoses of diabetes, coronary heart disease, or both, with one or more measures of poor disease control within the previous 12 months. Patients were randomized to the intervention group or the control group, in which they received enhanced usual care. Patients in the enhanced usual care group were advised to consult with their primary care physician to receive care for depression and for diabetes, coronary heart disease, or both, and with the patients' permission, their primary care physicians received results from the measures of depression and physical health at baseline and at 6- and 12-month follow-ups. Patients who received enhanced usual care could self-refer to mental health care, or primary care physicians in their health maintenance organization plan could refer them.

Patients in the intervention group had a greater improvement in social role disability compared with those in the control group from baseline to the 6-month follow-up (p = .006) and from baseline to the 12-month follow-up (p = .006).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)
Outcome 5: Cost-effectiveness
Description of Measures Cost-effectiveness was assessed with a calculation of the ratios of outpatient program costs per number of depression-free days (DFDs) and number of quality-adjusted life-years (QALYs). Each component was formulated as follows:

  • Outpatient program cost was calculated from the perspective of the health care system. Data on use and cost of services were taken from the health care plan's computerized cost accounting records. Costs for intervention services provided by the study, including supervision by physicians, were calculated using actual salary and fringe benefit rates plus a 30% overhead rate (e.g., administrative support, clinic space). Estimated costs for intervention services, including time required for recordkeeping and outreach efforts, were $79 for each in-person nurse visit (typically 30 minutes) and $31 for each telephone contact (typically 10-15 minutes, plus approximately 45 minutes of nurse time). Intervention costs also included a fixed cost of $100 per participant for physician supervision and information system support.
  • The number of DFDs was estimated through the integration of scores on the Symptom Checklist-20 (SCL-20) at baseline and at 6, 12, 18, and 24 months. The SCL-20 consists of a 13-item depression scale and 7 items intended to more completely assess criterion symptoms and improve responsiveness. Using a 5-point scale ranging from 0 (not at all) to 4 (extremely), respondents rate each item. Higher scores indicate more symptoms with greater intensity.
  • The number of QALYs was estimated on the basis of changes in differences of DFDs and in HbA1c, systolic blood pressure, and LDL-C levels between patients in the intervention and control groups from baseline to 24 months.
Key Findings A study was conducted with patients who were recruited from primary care clinics; met certain requirements for major depression; and had diagnoses of diabetes, coronary heart disease, or both, with one or more measures of poor disease control within the previous 12 months. Patients were randomized to the intervention group or the control group, in which they received enhanced usual care. Patients in the enhanced usual care group were advised to consult with their primary care physician to receive care for depression and for diabetes, coronary heart disease, or both, and with the patients' permission, their primary care physicians received results from the measures of depression and physical health at baseline and at 6-, 12-, 18-, and 24-month follow-ups. Patients who received enhanced usual care could self-refer to mental health care, or primary care physicians in their health maintenance organization plan could refer them.

Over 24 months, compared with the control condition and adjusted for age, sex, and previous 12-month outpatient costs, the intervention condition had a mean cost savings of $5.26 per DFD (95% confidence interval [CI] = -$29.76 to $19.17). Also over 24 months, compared with the control condition and adjusted for age, sex, and previous 12-month outpatient costs, the intervention condition had a mean cost savings of $1,773 per QALY (95% CI = -$2,878 to $2,878).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult)
55+ (Older adult)
51.9% Female
48.1% Male
75.2% White
6.5% Race/ethnicity unspecified
6.1% American Indian or Alaska Native
4.7% Black or African American
3.3% Asian
2.3% Native Hawaiian or other Pacific Islander
1.9% Hispanic or Latino

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Depression and physical health 3.8 3.8 3.3 4.0 3.0 4.0 3.6
2: Depression 3.9 4.0 3.3 3.8 3.0 4.0 3.7
3: Medication adjustment 3.5 3.8 3.3 3.8 3.0 4.0 3.5
4: Social role disability 3.8 3.8 3.3 3.8 3.0 3.8 3.5
5: Cost-effectiveness 3.5 3.8 3.5 3.8 3.0 3.5 3.5

Study Strengths

Outcomes were assessed by well-known scales with demonstrated reliability and validity. Data included laboratory tests and biological markers, as well as self-reports, which increased confidence in findings. Careful attention was given to fidelity of implementation, including the use of an implementation manual, training, and supervision. Nurses and physicians used an electronic registry, which allowed them to review the disease control measures for their patients, affording them the capability to ensure that treatment recommendations were implemented and to adjust the intensity of treatment with patients who were not responding. For the first 40 patients in the intervention group, all three teams of nurses and physicians met to discuss cases and to ensure that similar approaches were applied to disease management. Outcome differences between patients in the intervention group and those who received enhanced usual care were similar across the three nurses implementing the program. There was a high rate of participation and a low dropout rate, with little missing data. Patients were randomly assigned to receive the intervention or enhanced usual care, which resulted in equivalent groups. Analyses were thorough and appropriate, using an intent-to-treat approach.

Study Weaknesses

No psychometric properties were presented for the fidelity instrument. It was not clear how participants who dropped out of the study compared with study completers. The researchers noted several study limitations, which could have created potential confounding factors (e.g., the absence of a comparison group with the same number of visits as the intervention group, potential spillover of the intervention from primary care physicians caring for patients in both study groups).

Readiness for Dissemination
Review Date: October 2013

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Katon, W. (2012). TEAMcare intervention manual. Seattle: University of Washington/Group Health Cooperative.

Katon, W. (n.d.). TEAMcare overview [Training slides]. Seattle: University of Washington/Group Health Cooperative.

Program Web site, http://www.teamcarehealth.org/

Research studies:

Supporting materials:

  • Antidepressant Medications [List]
  • EPICare Patient List Tracking Tool [Notes]
  • GAD-7
  • Patient Health Questionnaire (PHQ-9)
  • TEAMcare Clinical Case Review [DVD]
  • Training handouts

TEAMcare. (2011). Starting bedtime insulin. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2011). Starting daytime insulin and carbohydrate counting. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2011). TEAMcare intervention timeline. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2011). TEAMcare: My better health plan. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2011). TEAMcare treat-to-target tools. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2011). TEAMcare visit tools: Follow-up visits. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2011). TEAMcare visit tools: Visit 1. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2011). TEAMcare visit tools: Visit 2. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2011). Your relapse prevention plan. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2012). Assessment of participant organizations/providers tasks and roles (adapted from IMPACT) [Sample]. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2012). TEAMcare clinical care action list. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2012). TEAMcare training [Agenda]. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2012). Weekly clinical outcome report [Sample]. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2013). TEAMcare clinical checklist. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (2013). Training and implementation services. Seattle: University of Washington/Group Health Cooperative.

TEAMcare. (n.d.). Tools for managing your chronic diseases. Seattle: University of Washington/Group Health Cooperative.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.8 3.5 3.2 3.5

Dissemination Strengths

Implementation materials are extensive and well organized. The intervention manual provides detailed information on delivering the intervention, including guidance on implementation at the clinic or health system level. All implementation materials are easy to obtain through the program Web site. Comprehensive on-site or online training is available. Monthly implementation consultation calls with developers are available to help ensure fidelity through discussion of quality of care and outcomes data. Developers help new implementation teams work together more effectively to decrease variability in outcomes.

Dissemination Weaknesses

The number of materials and the staffing and technology requirements may be overwhelming to sites with limited resources and limited experience with care coordination. Training relies heavily on a didactic approach, with limited practice of concepts by trainees. Except for consultation with the developers, there are no other tools or procedures to support the monitoring of fidelity.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
2-day, off-site training in Seattle, WA (includes slides, training handouts, and continuing education credit) $445 per participant Yes, one training option is required
2-day, on-site training (includes slides, training handouts, and continuing education credit) $40,000 for up to 40 participants and $54,000 for 41-60 participants, with costs varying by location Yes, one training option is required
1-day, on-site booster training $24,000 for up to 60 participants, plus travel expenses No
2-hour booster training via Webinar $5,800 for up to 25 participants No
3-hour, self-paced introductory or refresher course (includes continuing education credit) $150 per person No
1-hour implementation consultation calls (monthly, for up to 1 year) $1,322 per hour for up to 50 participants No
Computerized patient data registry Varies depending on type of software used and whether it is developed by the implementation team or purchased Yes

Additional Information

Customized training and support packages are available.

Contact Information

To learn more about implementation or research, contact:
Wayne J. Katon, M.D.
(206) 543-7177
wkaton@uw.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):