Nurse Care Management Improves Depression Outcomes
By Debra Wood, RN, contributorIt’s a prescription for success—by adding education and caring concern to a primary-care physician’s treatment plan, nurse care managers significantly improve depressed patients’ outcomes. “I’ve seen it work,” said lead author John W. Williams Jr., M.D., a staff physician at the Durham Veterans Affairs Medical Center in North Carolina and a professor of medicine and psychiatry at Duke University. “It’s clear a part of it is that patients get closer follow up … My impression is that some of it is feeling cared for. An empathetic person who expresses interest in you has some healing effects.” Care management relies on a team approach, with a nurse in the primary-care providers’ office monitoring patients by phone or during office visits. The nurses assess patients’ response to therapy using a standard tool; educate about depression and self-management; and communicate with a consulting psychiatrist and the primary-care physician. “The focus of the nursing intervention is education about the disease of depression and the treatment,” said Yvonne Porterfield, RN, MSN, co-clinical director for the eCare project at Kaiser Permanente in California and a depression care manager during the multicenter Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) trial. “We did health counseling about medications and dealing with side effects,” Porterfield continued. “The fifth focus was behavioral activation--cognitive behavioral therapy and increasing the amount of activity, especially pleasant activity.” IMPACT participants not taking antidepressants also received problem-solving therapy, helping them deal with issues of daily life. Williams and other researchers reviewed the findings of 28 randomized controlled trials, including IMPACT, totaling nearly 11,000 patients. They reported their review in the journal General Hospital Psychiatry. In 20 of the studies, patients experienced improvements in mental, social, physical or work functioning for up to one year, and in three of those, the benefits persisted for nearly five years. Most of the studies took place in large health-care organizations. Although research supports employing nurses as depression care managers, few systems have adopted the model. “There are many reasons it is tough to do,” Williams said. “It’s a change in the way we practice medicine. It involves mental health and primary care working together. It involves a team concept of care, and for some physicians, that is not how they practice or want to practice.” Williams said the care management models supervised by a psychiatrist have greater success, at least in part, because it makes the program more palatable to primary-care physicians who seem more willing to accept advice from a psychiatrist than a nurse. Paying for the care manager also poses problems. Smaller practices, with two or three physicians, cannot afford to hire a nurse to manage depressed patients, Williams said. Kaiser Permanente and the Veterans Health Administration have incorporated nurse care managers in their depression treatment plans, Williams said. Both are insurers as well as providers. “The VA system, we don’t have a lot of turnover of patients,” Williams said. “The VA can make longer-term investments, because the population is stable.” In Southern California, Kaiser cardiac care case managers are using the depression model to identify and improve treatment for heart patients also suffering from depression, said Porterfield, who helped design the program and train the nurses. “There’s a linkage between some heart problems and depression,” Porterfield said. “Treating depression improves health outcomes in this population.” Nurses will assess patients, provide health counseling and assist with medication management. Mental-health professionals will provide the counseling component. Frequency of telephonic visits varies, with nurses calling more often at the start of treatment, and then stretching contact out to monthly or less often when the patient stabilizes. Williams said some practices have hired nurse practitioners to provide the follow up in the office, so they can bill for the visit. Nurses with psychiatric and medical backgrounds seem to easily transition into depression care management and appreciate the collegial nature of the position. “It’s an opportunity to learn a new skill set,” Williams said. “Nurses find it challenging work. It is challenging to work with depressed patients, but they also find it interesting.” Porterfield agrees. “All the nurses who participated were enthusiastic about the program,” said Porterfield about the IMPACT trial. “They got a lot of job satisfaction and had a nice patient response. There was an interpersonal response and not just the good outcomes of depression. I liked that.”
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