Please select the eligibility criteria that correspond to the clinical trial below.
Title: TeamCare PCN: Collaborative Care for Patients With Diabetes and Depression in Primary Care Networks
Brief Summary: Background \& Objective: Type 2 diabetes is a complex disease characterized by multiple comorbidities. Depression is one of the most common comorbidities in individuals with diabetes with prevalence rates reaching 30%. Depression complicates diabetes treatment, portends worse outcomes and increases health care costs. One novel approach to managing diabetes with co-morbid depression is a collaborative primary care model involving a multidisciplinary health care team guiding patient-centered care. This model has been tested in the US and showed a significant reduction of depressive symptoms, improved diabetes care and patient-reported outcomes, and saved money. Our aim is to evaluate the implementation of this collaborative care model for type 2 diabetes and comorbid depression within the non-metro Primary Care Network (PCN) setting in Canada.

Intervention: The intervention involves three phases: (1) improving depressive symptoms, (2) improving blood sugar, blood pressure and cholesterol, and (3) improving lifestyle behaviours. The intervention is administered by a CM in collaboration with family physicians, psychiatrists, and internists.

Hypotheses: The TeamCare-PCN intervention will reduce depressive symptoms, achieve targets for cardio-metabolic measures and improve lifestyle behaviours. Furthermore, the investigators anticipate this intervention will be acceptable and implemented in a cost-effective manner in the PCN environment.

Methods: The investigators will employ a mixed-methods approach to our evaluation, using a controlled "on-off" trial design. Our primary analysis will be based on a multivariable scaled marginal model for the combined outcome of depressive symptoms and medical care. Secondary analyses will assess changes in lifestyle behaviours and patient-reported outcomes.

Significance: Our work will serve as a platform upon which an emerging model of primary care can incorporate an effective and cost-effective depression intervention into the management of individuals with type 2 diabetes, and as a framework for implementing and evaluating similar interventions in individuals with other chronic conditions.


Options:
A: Inclusion Criteria:

* medical patients discharged to home or skilled nursing facility between October 1, 2011 and June 30, 2013
* Cambridge Health Alliance PCP at time of discharge
* at least one of four risk factors for readmission: discharge diagnosis of CHF or COPD; length of stay \>3 days; age \>60; or previous hospitalization within the past 6 months
B: Inclusion Criteria:

* patients aged 65 years and older
* must have a minimum of three chronic or vitality threatening diseases and/or use five or more medical drugs chronically in the last year
* must have dyspnea and/or reduced exercise tolerance (scored by two short questionnaires)

Exclusion Criteria:

* patients with both confirmed COPD and heart failure (Spirometry performed \< 1 year ago and heart failure confirmed by echocardiography)
* patients unable or unwilling to sign informed consent
C: Inclusion Criteria:

* Workers with at least one chronic physical condition (\> 6 months).
* Working full time (at least 20 hours per week).
* Able to read and speak in English language.

Exclusion Criteria:

* Impending retirement or major career change (next 12 months).
* Not available to attend group workshops after working hours.
D: Inclusion Criteria:

* Have family physician-identified type 2 diabetes
* 18 years of age or older
* Score \>=10 on the PHQ-9
* Speak English and have adequate hearing to complete phone interviews
* Be willing and able to provide written informed consent to participate

Exclusion Criteria:

* Severe and/or terminal physical illness
* Serious and/or severe mental or psychiatric illness
* Pregnant or breastfeeding
* Live in long term care facility
* Already participating in other clinical trials

Answer: D