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Implementation of the Nurse Care Manager in

Integrated Care: A Systematic Report
Elizabeth Adams
egadams@usfca.edu

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Running head: NURSE CARE MANAGER IN INTEGRATED CARE 1

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

Elizabeth G. Adams

University of San Francisco

NURSE CARE MANAGER IN INTEGRATED CARE 2

Abstract

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).

Objectives

Although evidence demonstrates that the CCM is effective with nurses in the integrated

care CM role, there is a need to review how this intervention is operationalized when caring for

patients with depression and a long-term or chronic medical condition in an integrated PC

setting. The purpose of this review is to provide readers with a critical review of the evidence for

what elements of a collaborative nurse CM role have been be successful in supporting patients

with depression and chronic medical illnesses in an integrated PC setting.

Methods

The PICO(T) question that guided the review of the evidence was, “In a collaborative PC

setting, what designs for a nurse-led CM intervention have been successful in improving

depressive symptoms in adults with depression and a chronic health condition over three to

twelve months?” In October 2018, the Cumulative Index of Nursing and Allied Health

Literature (CINAHL), PubMed, Psych Info, Scopus, and the Cochrane Library were searched

using the following key search terms: collaborative care, care manage*, nurs*, depress*, care,
NURSE CARE MANAGER IN INTEGRATED CARE 6

manage*, primary care. The search of CINAHL yielded 190 results, PubMed yielded 164

results, Psych Info yielded 104 results, Scopus yielded 81 results, and the Cochrane Library

yielded 6 results. Articles were considered if they were published within the last ten years, were

published in English, were based in a PC setting, evaluated depressive symptoms with a

validated tool, included patients with a diagnosis of a chronic medical condition in addition to

one of depression, and involved a nurse-led CM intervention. Articles that outlined a study

prospectus were not included, though their final reports were searched for. Studies also had to

clearly define what their nurse CM intervention included, and were excluded if they did not.

Five articles were selected for appraisal based on relevance to the PICO(T) question and meeting

all inclusion criteria (see Figure 1.) The Johns Hopkins Research Evidence Appraisal Tool was

used to evaluate the selected articles (Dang & Dearholt, 2018). Three of the articles in this

review were Level I, Grade A, one was Level I, Grade B, and one was Level II, Grade A (see

Table 1, Table 2, and Table 3).

Discussion

Evidence Reviewed

The studies reviewed explored different designs of the care manager role (see Figure 2).

Ekers et al. (2013) conducted a systematic review and meta-analysis of randomized controlled

trials that tested nurse CM interventions in adults at least 16 years of age who had depression, as

well as a long-term health issue. The effects of nurse CM interventions across 14 randomized-

controlled trials and 4440 participants were analyzed. Studies were included in the review if

they provided care with at least two or more of the following components of collaborative care:

proactive follow-up of patients; assessment of care plan adherence; monitoring of symptoms

with evidence-based tools; care plan or medication adjustment as indicated; psychological

NURSE CARE MANAGER IN INTEGRATED CARE 7

support being available; and regular communication between the primary care providers and

mental health staff. Ekers et al. (2013) found the mean effect size on depression symptoms to be

moderate, d = 0.43 (95% CI [0.34, 0.52], p < 0.001, NNT 4.23). However, not all of the studies

reviewed were in a PC setting, and many of these studies are now over ten years old. Not all of

the studies in this review were relevant to answering the question of how a nurse CM

intervention should be operationalized, and what training elements were required.

Katon et al. (2010) and Morgan et al. (2013) were included in Ekers et al. (2013)’s meta-

analysis, and were also found in this review’s search strategy. These studies are both Level I,

Grade A evidence, and describe their interventions in detail (See Table 1 and Table 2). Katon et

al. (2010) conducted a single-blind randomized-controlled trail in fourteen integrated PC

settings, involving 214 adults with diabetes and/or coronary heart disease, as well as depression.

Their nurse-led intervention in an integrated care setting demonstrated a significant improvement

in the physical markers of hemoglobin A1C, low-density lipoprotein cholesterol, systolic blood

pressure, and depression, as measured by the Symptom Checklist Depression Scale -20, at 12

months (p < 0.001, Katon et al., 2010). The fact that PCPs cared for both the intervention group

and the control group is a limitation, as the increased awareness of mental health issues may

have influenced care to the control group (Katon et al., 2010). Lin et al. (2012) did further

analysis on Katon et al. (2010)’s data, and found that at twelve months after the intervention,

those in the intervention group had significantly higher rates of self-monitoring of blood pressure

and blood glucose as compared to the control group (RR=3.20, p < 0.001, RR=1.28, p = .006,

respectively). They also found that the intervention group had significantly more new

medication starts than those in the control group (Lin et al., 2012).
NURSE CARE MANAGER IN INTEGRATED CARE 8

Morgan et al. (2013) conducted a two-arm open random cluster trial with a waitlist

control of six months, followed for twelve months in Australian PC clinics, in 400 adults with

depression and diabetes mellitus type two, or coronary heart disease. They saw improvements in

both groups' PHQ-9 scores at six months, but significantly greater improvements in the

intervention group compared to control group (F(1,209)=6.40, p=0.012, Morgan et al., 2013). In

those with moderate-to-severe depression, these improvements were clinically significant. They

suspect that the control group had improvements in depression symptoms because clinicians

were more aware of the comorbidity of depression with diabetes and heart disease, as evidenced

by the significant increase in mental health referrals in the control group during the study period

(p < 0.001; Morgan et al., 2013). Furthermore, there were significant improvement in numbers

of referrals to and engagement in exercise plans and mental health work in the intervention

groups at both six and twelve months. Significant improvements in Short Form Health Survey-

36 version two, which assesses mental and physical health, were observed at both six (p=0.034,

p=0.023, respectively) and twelve months in the intervention groups (Morgan et al., 2013).

Limitations of this study include the fact that they did not comprehensively discuss their other

elements of their CCM, and the control group may have been more aware of mental health issues

by participating in the study (Morgan et al., 2013).

Johnson et al. (2014) conducted a pragmatic, controlled implementation trial in PC

settings in Alberta, Canada, in 157 patients with depression and type two diabetes. They found

greater improvements in PHQ scores in the intervention group compared to control group

(difference of 2.0, 95% CI [0.4, 3.7], p = 0.015; Johnson et al., 2014). There were also clinically

significant improvements in the depression symptoms in the intervention group compared to

active-control (p =0.03) and significantly less improvement in PHQ scores in the non-screened
NURSE CARE MANAGER IN INTEGRATED CARE 9

controls, compared to intervention group (p < 0.001, Johnson et al., 2014). Strengths of this

study include their thorough description of their intervention, but one must consider the unique

aspects of the Canadian healthcare system when considering its applicability to the United States.

Frequency and Modality of Contact with Patients

Differences existed in the frequency, length, and modality of patient and nurse CM

contact across the studies. However, Ekers et al. (2013) found in their meta-analysis that while

nurse CM visits ranged from four to twelve across studies, outcomes were similar. In Johnson et

al (2014), nurse CM appointments occurred one to two times per month, by phone or in-person.

Morgan et al. (2013) had nurse CM 45 minute, in-person visits every three months, while Katon

et al. (2010) had in-person nurse CM visits every two to three weeks. Once the patient achieved

remission, telephone appointments were done every four weeks (Katon et al., 2010). All studies

discussed the importance of regular nurse CM follow-up.

Components of CM Intervention

All of the studies reviewed provided some kind of psychological support intervention.

Ekers et al. (2013) did not discuss all of the specific psychological support interventions that the

included studies used, though they did specifically reference behavioral activation and problem

solving therapy, which are therapies based in cognitive behavior therapy. Behavioral activation

is a brief psychological support intervention based in which the depressed individual is supported

in engaging in activities that once brought them joy (University of Michigan, n.d.). By doing so,

depressive symptoms improve, and the cycle of avoiding pleasurable activities and feeling more

depressed is broken. Problem solving therapy is a brief therapy model in which the client’s

depressive symptoms are improved through guiding them through the process of solving

problems (National Network of PST Clinicians, Trainers, and Researchers, n.d.). The
NURSE CARE MANAGER IN INTEGRATED CARE 10

individual’s problem solving skills and confidence improve in this seven-step therapy model.

Johnson et al. (2014), Morgan et al. (2013) and Katon et al. (2010) all had behavioral activation,

problem solving, goal setting, and patient self-management skills in their nurse CM programs.

Johnson et al. (2014) and Morgan et al. (2013) also found motivational interviewing to be useful

in their interventions. Motivational interviewing is a counseling approach and a way of being

with clients that elicits desire for behavior change through non-judgmentally exploring and

resolving ambivalence in the client (University of Massachusettes Amherst, n.d.).

Psychoeducation is a psychological support intervention that involves educating the client about

their psychological illness, treatment options, and prognosis (Zhao, Sampson, Xia, & Jayaram,

2015). Psychoeducation and education regarding self-management were also common

components across the four studies.

In these visits, medication follow-up was conducted, and medication was adjusted based

on nurse protocol or consultation with the prescribing clinician (Ekers et al., 2013; Johnson et al.,

2014; Katon et al., 2010; Morgan et al., 2013). Depressive symptom check-in was in all of the

studies’ nurse CM designs, and often the PHQ-9 was used to monitor depressive symptoms.

Utilization of a patient-centered care plan was evident across the studies reviewed. Goal

setting and following up with patients about progress towards goals was also discussed, and the

nurse CM would help the patient identify and overcome barriers to achieving their goals

(Johnson et al., 2014; Katon et al., 2010; Morgan et al., 2013). Katon et al. (2010) and Johnson

et al. (2014) had the nurse CM develop a relapse prevention plan with patients after they

achieved remission of their depression. Morgan et al. (2014) included referral follow-up,

lifestyle risk factor review, and monitoring of physical measures in their nurse CM check-ins,

while Katon et al. (2010) included diet and exercise components of their care plans. While all
NURSE CARE MANAGER IN INTEGRATED CARE 11

studies had the nurse CM check-in and collaborate with other team members regularly, only

Johnson et al. (2014) actually shared the care plan itself amongst team-members and with the

patient.

Training of CM

Though Ekers et al. (2013) found variation in length of training to be up to seven days,

Johnson et al. (2014), Morgan et al. (2013), and Katon et al. (2010) all held two-day training

sessions for their nurse CMs. The content of the trainings in the studies reviewed by Ekers et al.

(2013) included instruction in behavioral support interventions, administration of the

psychological assessment tools, education about depression and pertinent medical symptoms in

their instruction design. The training in Katon et al. (2010) was led by a psychologist, a

psychiatrist, PC providers, an endocrinologist and nephrologist, who specifically spoke about

diabetes. The other studies did not discuss who specifically led the training.

Implications for Practice

It is important that the nurse CM intervention be appropriate to the practice setting. The

studies reviewed utilized different expectations for frequency, duration, and mode of patient

contact. Since there was no significant difference in outcomes between telephone or face-to-face

patient contact, it would be wise for the practice to design an intervention that is most

appropriate to their patient population (Ekers et al., 2013). It may be practical for the nurse CM

to have both in-person and telephone contact with patients, as this design is supported by the

literature and may be more accessible for patients. Regardless of the modality of

communication, the nurse CM should have regular, pro-active contact with the patient. The

content of these visits should be thoughtfully constructed.

NURSE CARE MANAGER IN INTEGRATED CARE 12

Practices should design their nurse CM visits to include regular follow-up evaluation of

depression symptoms, medication adherence, and need for treatment adjustment. Some practices

may be ready to have the nurse CM adjust medications based on protocols, while others may

want to continue clinician-driven adjustments. Regardless, interdisciplinary collaboration is

important in this model. The nurse’s interdisciplinary care plan itself may be utilized to help

support this collaboration amongst care providers, as well as with the patient (Johnson et al.,

2014).

Helping the patient set goals, and supporting them in identifying and overcoming barriers

to achieving these goals, were also common elements in these intervention designs (Ekers et al.,

2013; Johnson et al., 2014; Katon et al., 2010; Morgan et al., 2013). Behavioral activation may

be included in these goals to help support depression improvement. Education, motivational

interviewing, and problem solving skills can help the patient in achieving their goals.

Training of the nurse CM should be relevant to the elements included in the intervention.

Having colleagues from different disciplines in the practice lead the training may be helpful both

in educating the nurse CM but also in fostering interdisciplinary relationships, which may lead to

better interdisciplinary management of these patients. Training does not have to be extensive, as

the studies reviewed only had two-day trainings, but having continual access to and support from

other team members is helpful in this model.

Conclusion

Although there is strong evidence supporting the CCM, and the CM is an essential

component of this model, differences exist in CM role implementation. Nurses have been

successful as the CM, and having the nursing background may be especially important in

supporting patients with complex medical conditions. Furthermore, nurses are trained to see the
NURSE CARE MANAGER IN INTEGRATED CARE 13

patient as a whole person, integrating the behavioral, medical, and psychosocial in the patient-

centered care plan development. Despite the volume of existing evidence about the CCM,

evidence on how to implement a nurse CM intervention in a PC setting with adults with

depression and a chronic medical condition remains limited. A review of the existing evidence

suggests the importance of regular patient follow-up, goal setting, problem solving, behavioral

activation, treatment plan engagement, symptom identification and medication adherence in the

nurse CM intervention. While there is no standard training requirement for this role, training

plans should be designed such that the nurse CM feels equipped to adequately fulfill the care

plan elements. Regular contact with other care team members may support the success of this

role. Further research is needed regarding the best way to operationalize the nurse CM role in an

integrated care setting, and should explore the potential that exists in this role.

Elizabeth Adams has no conflicts of interest.

NURSE CARE MANAGER IN INTEGRATED CARE 14

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NURSE CARE MANAGER IN INTEGRATED CARE 18

Figure 1. Search results. The search was conducted in October 2018, using search terms

collaborative care, care manage*, nurs*, depress*, care, manage*, primary care.
NURSE CARE MANAGER IN INTEGRATED CARE 19

Figure 2. Elements of the nurse care manager intervention. The “?” indicates that it was not

explicitly addressed. Table structure adapted from Melnyk, B.M. & Fineout-Overholt, E., 2015.
Running head: NURSE CARE MANAGER IN INTEGRATED CARE 20

Table 1. Evidence Table Part One of Three

NURSE CARE MANAGER IN INTEGRATED CARE 21

Table 2. Evidence Table Part Two of Three

NURSE CARE MANAGER IN INTEGRATED CARE 22

Table 3. Evidence Table Part Three of Three