The expanding number of people with multiple physical and mental chronic conditions are among the toughest, and costliest, to care for. The TEAMcare collaborative care program offers a promising solution.

In the January/February 2012 Annals of Family Medicine, Group Health Research Institute and UW Medicine researchers found how this program works: through primary-care doctors starting and adjusting medications sooner and more often to reach goals ("treating to target"); and motivating patients to participate in their own care and monitor their illnesses.

"We have shown that it's effective when nurses work with patients and health teams to manage care for depression and physical diseases together, using evidence-based guidelines," said Elizabeth H.B. Lin, MD, MPH, a Group Health family physician and an affiliate investigator at Group Health Research Institute.

With Wayne J. Katon, a UW professor of psychiatry and behavioral sciences and an affiliate investigator at Group Health Research Institute, Dr. Lin and others published a randomized controlled trial in the New England Journal of Medicine. They reported that TEAMcare resulted in less depression and better-controlled blood pressure, sugar, and cholesterol levels for 214 Group Health Cooperative patients with depression and diabetes and/or heart disease.

With Michael Von Korff, ScD, a senior investigator at Group Health Research Institute, the same research group also published in the British Medical Journal that these patients had better quality of life and less disability than did patients with usual care. "These are the outcomes that matter most to patients," Dr. Lin said. And they suggest that TEAMcare may help people with multiple chronic diseases to age in the healthiest possible way.

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"Now we've shown why this team-based care is effective," Dr. Lin said. "It's because it activates patients to check their own blood pressure and sugar more - and primary-care doctors to adjust patients' medications sooner and more often."

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After a year of the program, medication was six times more likely to be started or adjusted for antidepressants, three times more likely for insulin, and nearly two times more for antihypertensive medications among TEAMcare relative to usual care patients. And TEAMcare patients monitored their own blood pressure three times more often and their blood glucose on significantly more days per week.

"We found no difference in medication adherence between the TEAMcare patients and those with usual care," Dr. Lin said. This may be because adherence rates were already high for both groups at baseline: 79 percent to 86 percent, depending on the drug class. "But in other settings, where medication adherence is lower, helping patients to stick more closely to their prescriptions would likely be more important," she added.

"When patients are depressed and have multiple uncontrolled chronic diseases, they are at high risk of heart attack, stroke, and other complications," Dr. Lin said. "Multiple health problems can feel overwhelming - for patients, their families and their health care providers. It is hard for primary-care doctors to manage these patients without support like TEAMcare. That support coordinated care, empowered patients to control their diseases better, and helped primary-care doctors to collaborate with various specialists, monitor progress closely, and adjust medications to treat to individualized goals.

"Interest is high in spreading integrated, coordinated, team-based care for patients with depression and poorly controlled physical diseases," Dr. Lin said. She is leading a project to implement TEAMcare as part of usual primary care at Group Health, and there is also interest in spreading the program to other organizations.

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TEAMcare is a patient-centered program that is based on the Chronic Care Model and "treating to target": Together, the nurse and patient set realistic step-by-step goals: improving function and quality of life and reducing depression and blood sugar, pressure, and cholesterol levels. To reach these goals, the nurse regularly monitored the patient's mental and physical health. Based on guidelines that promoted incremental improvements, the multidisciplinary care team offered recommendations to the patient's primary care doctor to consider treatment changes to manage blood pressure, blood sugar, lipids, or depression.

The National Institute of Mental Health (NIMH) funded the TEAMcare trial and this research. In addition to Drs. Katon and Von Korff, Dr. Lin's other co-authors were: Do Peterson, MS, Evette J. Ludman, PhD, Malia Oliver, and Mary McGregor, MN, of Group Health Research Institute; Edward H. Wagner, MD, MPH, of the MacColl Center for Health Care Innovation at Group Health Research Institute; Carolyn M. Rutter, PhD, of Group Health Research Institute and the Department of Biostatistics of the UW School of Public Health; David K. McCulloch, MD, of Group Health; Paul Ciechanowski, MDCM, MPH, of the UW School of Medicine's Department of Psychiatry and Behavioral Sciences and affiliate investigators at Group Health Research Institute; Bessie A. Young, MD, MPH, of the UW School of Medicine's Department of Medicine and Veterans Affairs Puget Sound Health Care; and Jochen Gensichen, MD, MA, MPH, of the University of Jena in Germany.

Group Health Research Institute