TEAMcare: Treating the whole patient with the whole team

Story by Clare LaFond
Photos & video by Conrado Tapado

One of the most challenging and costly patient groups to care for is the growing number of people with multiple chronic illnesses – both physical and mental. Patients with diabetes and heart disease often suffer from depression, which can make them feel helpless and hopeless about managing their chronic disease. And that, in turn, can lead to more complications and even death. Read the news release.

But a promising collaborative care model known as TEAMcare puts the patient in the driver’s seat. By teaching patients the self-care skills they need to optimally control their chronic conditions, TEAMcare motivates patients to actively participate in their own health care. It’s a team-based approach involving nurses, psychiatrists, primary care physicians and other medical providers that’s delivered in the patient’s primary care clinic and by telephone. Working together, doctors start and adjust medications sooner and more often to reach goals — “treating to target” – and nurses work with patients and health teams to manage care for depression and physical diseases together. You could say it’s about treating “the whole patient” with “the whole team.”

Developed through a unique collaboration between the University of Washington and the Group Health Research Institute, TEAMcare’s multi-disciplinary team includes, among many others: Dr. Wayne Katon, a UW professor of psychiatry and behavioral sciences internationally renowned for his research on the impact of depression and anxiety on patients with chronic medical illness; and Dr. Paul Ciechanowski, a UW associate professor of psychiatry and director of the UW Center for Commercialization’s Training Xchange program, where he helps to bridge the gap between researchers and frontline users who provide services.

As one of seven programs currently available at Training Xchange, TEAMcare has brought together professionals from multiple disciplines to share information in new ways, using their clinical, research, and entrepreneurial knowledge. That collaborative work recently led to a success story at The Polyclinic, a Seattle-based multispecialty physician group. Using the TEAMcare program to treat patients with diabetes and major depression, The Polyclinic was able to successfully treat depression and achieve all three targets of blood glucose control, blood pressure control, and LDL cholesterol levels in 69 percent of patients who completed the program over four months. As a comparative benchmark, in many of the highest performing healthcare organizations nationwide, the proportion of patients with diabetes able to achieve those same desired levels outside of the TEAMcare approach is closer to 40%.

“I became dependent upon the [TEAMcare] calls,” describes one Polyclinic patient who participated in the program. “Because the nurse would remind me to take care of myself – to eat the right things, take my medicine on time, get exercise. And without that, I don’t think I would’ve been able to manage it.”

Today, more than 30 sites across North America are implementing TEAMcare as a ready solution for developing a patient-centered medical home model or accountable care organization. And overall costs of health care for patients treated with TEAMcare have been shown to be $600 to $1100 lower per patient over a two-year period.

To learn more about TEAMcare and how it is improving quality of care – and quality of life – for patients, visit and check out the new TEAMcare online course for health care providers.