Coronary heart disease (CHD) and type 2 diabetes mellitus (T2DM) are both major causes of disability. The incidence of T2DM is now reaching epidemic proportions in Australia [1
] and overseas [2
], particularly as the population ages and becomes more obese [3
]. Within 20 years diabetes will become the leading contributor to the overall burden of disease in Australia [4
] with Australian health care expenditure projected to increase to $7 billion by 2023 [5
]. CHD already affects over 300,000 people in Australia and remains the most common cause of death [6
]. Both diabetes and heart disease are associated with a number of serious complications, each with its own cost.
There is evidence that the presence of depression in patients with CHD or T2DM leads to increased morbidity and mortality [7
], but co-morbid depression is often missed in routine consultations within general practices [9
]. One difficulty is that the traditional model used by general practices is one in which visits to the general practitioner (GP) are initiated by patients when they feel that their needs warrant a consultation. Such visits are usually episodic and cease when the immediate symptoms are relieved. Consequently, such patients miss out on regular monitoring of their chronic disease so that risk factors go unrecognised [9
A collaborative model is one in which the care delivery has multiple components that address these problems [10
] and has been shown to have good results in treating depression [11
]. It relies on a case manager to coordinate that care. Hickie and McGorry [12
] summarise the planned episodes of care that include:
• Use of evidence based guidelines;
• Systematic screening and monitoring of risk factors;
• Timetabled recall visits;
• New or adjusted roles for team members;
• Information support for the clinician;
• Enhanced patient self-management;
• Identified case manager to coordinate care;
• A means of effective communication between all members of the care team; and
• Audit information for the practice.
The True Blue study described in this paper extends an exploratory trial to adapt the successful IMPACT model of collaborative care for depression in the USA [10
] to an Australian primary health care setting. The case manager in this study is the practice nurse (PN). The model of practice nurse-led collaborative care was demonstrated in six general practices in rural southern Australia, with 332 patients recruited [13
]. In this exploratory trial a practice nurse training programme was developed for chronic disease management, introducing depression screening and counselling techniques to assist with self-management. Electronically based multi-purpose tools were designed and tested to allow outcome data to be collected to inform coordinated medical care and patient self-management. The trial found depression in 34% of patients with CHD or T2DM, and demonstrated that the practice nurse-led, collaborative care model was both feasible and acceptable.
The role of practice nurses in collaborative care of chronic disease is being investigated both in Australia and overseas. [14
]. The features of the True Blue study are that the programme
• routinely screens for depression;
• monitors depression severity over time for participating patients;
• uses the existing work force and funding arrangements to potentially make the model more widely applicable;
• uses consultations with practice nurses that allow collection of physiological measurements, monitoring of lifestyle and mental health risks and setting of patient goals; and
• is linked with appointments to the patient's usual general practitioner (GP).
The present study works with this subset of patients who have co-morbid depression and aims to demonstrate improved clinical outcomes for this higher-risk group through measurements of physiological, mental health and lifestyle parameters at regular intervals throughout the study period. It will further test and implement this collaborative care model that is focussed on the patient. An important aspect is that patients, in collaboration with the practice nurse, will develop up to three goals that they feel will be able to help reduce their risk factors, thus making patients active participants in their own health care.
The model is also intended to demonstrate how the care of co-morbid depression, heart disease and diabetes can be funded successfully using Australian Medicare Benefits Schedule (MBS) Item numbers. It will develop training programmes for PNs in screening, assessment and management of patients with co-morbid depression and heart disease or diabetes, and evaluate the feasibility of PNs to carry out screening and assessment.
Objectives of this study
The primary objective of this study is to determine whether practice nurse-led collaborative care is better than the usual method of GP-led episodic care for the management of co-morbid depression in patients with heart disease or diabetes by testing whether there is an improvement in the depression score at the end of the study. The goal is to achieve a 50% reduction in that score. It will also test whether it is a practical way to manage this complex and increasing chronic-disease burden. It will introduce an hour-long consultation with the practice nurse in which patient goal setting forms an important proactive part of the patient care. One key strategy is that the patient outcomes will be reviewed every three months over an entire year and patient goals altered accordingly. Other objectives are to demonstrate that the model of care can use existing clinical staff and be funded within current Medicare arrangements, and that it can be used in large and small practices across rural and urban settings.