Lightening the load with team work

Collaborative care for the management of depression, heart disease and diabetes brings positive results. By Annie May.

Practice nurses can improve depression in patients with diabetes and heart disease, a recent study has found.

Researchers from the Greater Green Triangle University Department of Rural Health used a collaborative care model to monitor and treat depression alongside treatment for the underlying chronic disease and compared outcomes to usual GP care. The results clearly showed the collaborative model, where practice nurses (PNs) acted as case managers, got much better results, Dr Mark Morgan, senior research fellow at Flinders University, told the Primary Health Care Research Conference held in Brisbane in July.

“We now have the evidence to recommend this type of care for all Australian practices,” Morgan said.

Eleven practices from rural and urban areas were selected to provide collaborative care, referred to as True Blue, or usual care. Patients with diabetes or ischaemic heart disease completed the Patient-Health-Questionnaire-9 to identify those with depression, resulting in 328 patients taking part in the trial.

“Diabetes and heart disease are national priorities. In patient with type 2 diabetes or heart disease depression is common. This co-morbid depression is under recognised and under treated despite being one of the most significant risk factors for poor clinical outcomes,” Morgan said.

“A new model has to be implemented to stop these patients from falling through the gap.”
In True Blue intervention practices, patients saw the practice nurse then their GP every three months for one year. Nurses were trained to assess psychosocial, physical and behavioural risks, negotiate goals and to coordinate care.

At six months, the collaborative approach led to a reduction in depression scores, and at 12 months a reduction in blood pressure and reduced 10-year CVD risk were seen.

“This model resulted in remarkable adherence to best-practice guidelines for monitoring of chronic disease. There was intensification of depression management with increased exercise, behavioural activation goal setting, mental health referrals and prescriptions.

“The results further prove that a collaborative care approach is in the best interests of the patients. Practice nurses helped patients set goals and organised referrals, allowing the GP to focus on the clinical issues,” Morgan said.

The model has also expanded the nurses’ scope of practice, with those participating in the study reporting on an increased knowledge of depression and an increase in confidence when it comes to discussing mental health issues. n

Change in depression scores after six months of nurse-led care
• 36 per cent of patients achieved the targeted 50 per cent reduction in
PHQ-9 scores after six months of nurse-led care.
• A further 42 per cent of patients have shown improvement in PHQ-9 scores.
• Mean changes in PHQ-9 scores translate into a score after six months that is
between 57 per cent and 72 per cent of the initial score, with a mean change of 64 per cent.

Features of True Blue
• Medicare funded, using existing staff
• Practice nurses enhanced roles
• Information collation including mental health
• Goal setting
• Case management
• Information support for GPs
• Self management support for patients
• Automatic data collection.

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