NUR 676 Module 9 Final Project Example

Final Project: An Integrated Care Plan for Major Depression and Poorly Controlled Type 2 Diabetes

[Student Name]

Southern New Hampshire University

NUR 676: Primary Care for Mental Health

Module Nine Final Project

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Final Project: An Integrated Care Plan for Major Depression and Poorly Controlled Type 2 Diabetes

Depression and diabetes often occur together, and each makes the other harder to manage. Depression drains the energy and motivation needed for glucose monitoring, medication adherence, healthy eating and exercise, while the burden of a chronic illness and its complications can deepen depression. Treating them in separate silos, with the primary care clinician adjusting insulin and a distant mental health referral that may never happen, often fails both. Gloria, 58, attends a composite community clinic, and her diabetes and blood pressure have worsened as her mood has declined. This final project presents an integrated care plan. It argues that a single team treating depression and cardiometabolic risk factors to target together, with a nurse care manager coordinating care and measuring progress, can improve both mental and physical health.

The Patient

Gloria has had type 2 diabetes for twelve years and hypertension for eight. Over the past year, since her husband's death, her A1c has risen from 7.6% to 10.2% and her blood pressure has averaged 152/94. Her LDL cholesterol is 138 mg/dL. She reports taking metformin and her blood pressure medicine about half the time, having stopped checking her glucose because the numbers upset her and eating irregularly. Most days she feels low; her church group no longer interests her; sleeps poorly, feels tired and hopeless and has trouble concentrating. Asked plainly about self-harm, she says she has had no such thoughts, and she has never had a manic episode. She drinks no alcohol. Her daughter lives nearby and wants to help.

Diagnosis and Measurement

Kroenke et al. (2001) tested the PHQ-9 against clinical interviews in primary care and obstetric clinics, showing that its total tracks severity and that the 10-point threshold picks out major depression accurately; they also showed that it can be used to monitor change over time. Gloria's score of 17 indicates moderately severe depression, and the interview confirmed major depressive disorder, with bereavement having evolved into a persistent depressive episode with hopelessness and functional decline. Her negative mania history and bipolar screen support antidepressant treatment. The PHQ-9 will serve as her depression measure throughout, just as the A1c, blood pressure and LDL measure her physical health.

The Model: Treating to Target Together

Katon et al. (2010) conducted the TEAMcare trial, randomizing primary care patients with depression and poorly controlled diabetes, coronary heart disease or both to usual care or an intervention in which a nurse care manager, supervised by a primary care physician, a psychiatrist and a psychologist, worked with patients to set goals and adjusted treatment for depression, glucose, blood pressure and cholesterol according to protocols until targets were met. At twelve months, patients in the intervention group had greater improvements in A1c, LDL cholesterol, systolic blood pressure and depression, along with better quality of life and satisfaction with care. The trial showed that one coordinated approach could improve several conditions at once.

The structure builds on collaborative care for depression. The IMPACT trial showed that a care manager tracking depression scores and consulting weekly with a psychiatrist about patients not improving substantially increased the share of older adults whose depression improved (Unützer et al., 2002). TEAMcare extended that structure to medical conditions, which is why the clinic's care manager and consulting psychiatrist will be central to Gloria's plan.

Goals and Treatment

Gloria and the care manager set goals together: feeling well enough to return to her church group, a PHQ-9 below 10 at three months and below 5 at six months, an A1c below 8% at six months, blood pressure below 130/80 and LDL below 100 mg/dL. Depression treatment begins with sertraline 50 mg, chosen for its efficacy, tolerability and neutral effect on weight and glucose, increasing to 100 mg at four weeks if needed, plus grief-informed behavioral activation sessions with the clinic's therapist. For diabetes, adherence barriers were addressed before adding medication: pillbox setup with her daughter, a simpler once-daily regimen and a glucose meter that uploads readings so the care manager can review them. Empagliflozin was added to metformin for its glucose and cardiovascular benefits. Lisinopril was increased and atorvastatin started.

Roles and Visit Schedule

The nurse care manager contacts Gloria every two weeks by phone or in person, reviews her PHQ-9, glucose readings and blood pressure log and adjusts medications according to protocols approved by the primary care clinician. The family nurse practitioner sees her monthly for the first three months. The consulting psychiatrist reviews her case in weekly caseload meetings and steps in if her PHQ-9 has not been cut in half within two to three months. The therapist provides six behavioral activation sessions. Her daughter, with consent, joins one visit to learn how to support medication routines without taking over.

Measurement and Adjustment

Progress is tracked on a single dashboard showing PHQ-9, A1c every three months, blood pressure and LDL. When a measure is off target, the care manager adjusts treatment rather than waiting for a scheduled visit. If her PHQ-9 remains above 10 at twelve weeks despite adherence, the psychiatrist will recommend a dose change, a switch or augmentation. If her A1c remains above 9% at three months, insulin will be discussed. Suicide risk will be reassessed at each contact, since hopelessness and chronic illness increase risk.

Grief is part of Gloria's depression, and the plan respects that. The therapist's sessions will make room for her loss while helping her return to valued activities, beginning with one church event a week. The care manager will ask about the anniversary of her husband's death, which falls in the fourth month of treatment, and will schedule an extra contact that week, since anniversaries can bring a temporary setback in mood and self-care.

Conclusion

Gloria's rising A1c and blood pressure were bound up with depression after her husband's death. A plan that treats her depression and cardiometabolic risk factors to target together, coordinated by a nurse care manager with psychiatric consultation and measured on one dashboard, follows the model that improved both mental and physical outcomes in TEAMcare and gives her a realistic path back to health and to the community she has withdrawn from.

References

Katon, W. J., Lin, E. H. B., Von Korff, M., Ciechanowski, P., Ludman, E. J., Young, B., Peterson, D., Rutter, C. M., McGregor, M., & McCulloch, D. (2010). Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine, 363(27), 2611-2620. https://doi.org/10.1056/NEJMoa1003955

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr., Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H. B., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., & Langston, C. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA, 288(22), 2836-2845. https://doi.org/10.1001/jama.288.22.2836