Implementation of the Nurse Care Manager in Integrated Care: A Systematic Report

Introduction: The collaborative care model (CCM) is an effective model for improving depression symptoms in patients in a primary care (PC) setting. An essential role in this model is the care manager (CM), and nurses have been effective in this role. However, there remains a question of how to best design, train, and implement this nurse CM role in PC. Objectives: The purpose of this review is to provide readers with a critical description of what processes for training and implementation of a collaborative nurse CM role have been be successful in the literature, specifically as it pertains to supporting patients with depression and chronic medical illnesses in an integrated PC setting. Methods: A literature review of PubMed, CINAHL, PsychInfo, Scopus, and the Cochrane Collaborative was conducted in October 2018. Discussion: Successful nurse CM interventions have included regular patient follow-up, symptom check-in, treatment monitoring, goal setting, and education. Psychological support techniques such as problem solving therapy, behavioral activation, and motivational interviewing have been useful in supporting patient care-plan engagement and goal achievement. Nurse CM training should support the successful implementation of the designed role. Conclusion: Nurse CMs have an opportunity to significantly impact depressive outcomes of patients with depression and long-term health conditions. Further research is needed to explore the potential that this nursing role has, as well as how to best operationalize this role. NURSE CARE MANAGER IN INTEGRATED CARE 3 Implementation of the Nurse Care Manager in Integrated Care: A Systematic Report Introduction/Background Depression is a worldwide medical problem affecting 300 million individuals, and is the leading cause of disability (World Health Organization, 2018). The National Ambulatory Medical Care Survey revealed that in 2015, 59.8 million physician visits had depression as their primary diagnosis (Rui & Okeyode, 2015). These data are important, as consequences of depression can be severe. In 2014, 1.6% of deaths were attributed to intentional self-harm (suicide), making it the tenth leading cause of death (Kochanek, Murphy, & Tejada-Vera, 2016). Furthermore, depression is more common in people with chronic medical conditions than in the general population, and depression is a risk factor for heart disease, stroke, and diabetes mellitus (Clarke & Currie, 2009). Depression and diabetes mellitus can worsen both conditions’ outcomes, likely through both biological and behavioral variables (Holt et al., 2014). Depression and a co-morbid chronic health condition are associated with poorer quality of life and the combination can lead to poorer health outcomes (Naylor et al., 2012). The integration of mental health care into primary care has been shown to be effective in improving care for depression symptoms, as well as for people with chronic health conditions (Naylor et al., 2012). One of the models for integrating behavioral health into primary care is the collaborative care model (CCM). Developed in 1995, the CCM has been studied over the last two decades and has shown positive outcomes and symptom improvement (American Psychological Association & Academy of Psychosomatic Medicine, 2016; Katon et al., 1995). In the CCM, the care team often consists of the primary care (PC) provider, a care manager (CM), and a mental health specialist, such as a psychiatrist or a psychologist (Archer et al., 2012). Essential elements of the CCM include the interdisciplinary care team, population-based NURSE CARE MANAGER IN INTEGRATED CARE 4 care, measurement-guided care, and evidence-based care (Advancing Integrated Mental Health Solutions Center, n.d.; American Psychological Association & Academy of Psychosomatic Medicine, 2016). A Cochrane Collaborative review demonstrated that the CCM improved depression outcomes in the CCM intervention in zero to six months (standardized mean difference [SMD] = -0.34, 95% confidence interval [CI; -0.41, -0.27]; risk ratio [RR] = 1.32, 95% CI [1.22, 1.43]), seven to twelve months (SMD = -0.28, 95% CI [-0.41, -0.15]; RR = 1.31, 95% CI [1.17, 1.48]), and thirteen to twenty-four months (SMD = -0.35, 95% CI [-0.46, -0.24]; RR = 1.29, 95% CI [1.18, 1.41]; Archer et al., 2012). Additional improvements were also seen in medication compliance, mental health related quality of life, and treatment satisfaction among patients (Archer et al., 2012). As a part of the CCM, the CM often has regular contact with the patient, and helps coordinate care between the patient and other members of the care team (Archer et al., 2012). Although these themes are clear, the background and training of the CM, and how the CM executes the CCM CM principles vary across different studies and practices. Richards et al. (2013) designed a CM intervention that utilized mental health workers. Training consisted of a five-day training course, the content of which was not discussed (Richards et al., 2013). The Patient Health Questionnaire-Nine Item (PHQ-9) mean depression score was 1.33 points lower in the intervention group compared to the usual care group at four months (95% CI [0.35, 2.31]. p = 0.009), with a standard effect size of 0.28 (95% CI [1.22, 2.29]; Richards et al., 2013). Björkelund et al. (2013) used a nurse in the CM role, and that the intervention group’s Montgomery-Asberg Depression Score-Self depression scores were significantly lower than those of the control group at both three (-2.17, 95% CI [0.56, 3.79], p = 0.009) and six (-2.27, 95% CI [0.59, 3.95, p = 0.008) months). Training for their nurse CMs included one three-day training NURSE CARE MANAGER IN INTEGRATED CARE 5 before the intervention, and two one-day training during the intervention, though specifics of the training were not reviewed (Björkelund et al., 2018). Thota et al. (2012) reviewed 37 randomized control trials for collaborative care through 2004. Studies employed CMs with professional backgrounds as nurses, master’s level mental health workers, and social workers (Thota et al., 2012). The effect estimates were largest for registered nurses (Thota et al., 2012). Furthermore, given their background in the medical field, registered nurses are well suited to support patients with complex medical care needs and depression. Nurse CMs can help patients build confidence in themselves for managing long term conditions and improve patient quality of life (Askerud & Conder, 2017).