INTEGRATING MENTAL HEALTH CARE AND PRIMARY CARE SERVICES FOR
ADULTS WITH TYPE 2 DIABETES (T2DM) WHO HAVE DEPRESSION
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The incorporation of mental health care and patient-centred medical homes (PCMHs) for those
with comorbid depression and type 2 diabetes is key to addressing the complex needs of this
patient population. PCMHs, a comprehensive model, coordinated and patient-centric (Peterson
et al., 2020; Bowdoin et al., 2016), offer a promising approach to treating these conditions
concurrently. This literature review probes into the evidence on the feasibility of models of
service that combine mental health care and PCMH in improving the health outcomes of
patients with T2DM and depression. The review will pinpoint the idea of chronic care integration
within the genre of PCMHs in nursing practice, explain the proposed integration of mental health
services and PCMHs, and explain why this approach is rational and supported by evidence. The
blending of mental and physical health care through a PCMH is significant because it offers
better care coordination, outcomes, and cost-effectiveness for individuals with complex
conditions like T2DM and depression. This paper reviews the evidence on integrated care
models inside PCMHs for targeting the increasing prevalence of chronic conditions and the
overall burden on healthcare systems.
Definition of healthcare integration in nursing practice
The delivery of T2DM and depression healthcare services through the PCMH model requires a
holistic, coordinated, and collaborative approach to address the patients' both physical and mental
health problems simultaneously (Wang et al., 2022; Peterson et al., 2020). This integrated
approach recognizes the bi-directional relationship that exists between T2DM and depression,
which in turn acknowledges the impact that both conditions may have on each other. Basiri et al.
(2023) state that having a multidisciplinary team comprised of nurses, physicians, psychologists,
social workers, and dietitians is the key to addressing all the various healthcare issues at once in
the context of the PCMH model.
Proposed integration, rationale, and evidence base
The combination of mental health services and patient-focused medical homes (PCMHs) for
adults with T2DM and comorbid depression provides comprehensive care addressing the
complex connections between the two conditions. The PCMH collaborative care model is ideal
to address this issue, as T2DM is a disease with a high prevalence of depression among its
patients, and this, in turn, can negatively impact both health and quality of life
outcomes. Patients with type 2 diabetes are 1.5 to 3 times more likely to develop depression
than the general population (Semenkovich et al., 2015; Campayo et al., 2017). On the other
hand, individuals with depression also have a higher risk of developing T2DM because of
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factors such as unhealthy lifestyles, medication side effects, and physiological changes (Brown
et al., 2021; Coventry et al., 2015). The integration of mental health and PCMHs will tackle the
co-complexity of T2DM and depression in a holistic approach, marketing interventions that
enhance patient outcomes and overall well-being.
The findings of different studies have shown that within the PCMHs, collaborative care models
are effective for the reduction of depressive symptoms and for controlling HbA1c levels, thereby
improvement of quality of life and self-management behaviors in type 2 diabetes with concurrent
depression (Huang et al., 2013; Atlantis et al., 2014; Rossom et al., 2017; Wang et al., 2023;
Peterson et al., 2020). Research shows a link between depression treatment in T2DM patients
and better glycaemic control, healthcare behaviours, and general health status (Coventry et al.,
2015; Castañeda et al., 2022). Moreover, the interprofessional care models in PCMHs have
been considered successful, which has caused a reduction in healthcare spending as well as
related costs (Katon et al., 2012; Simon et al., 2007; Bowdoin et al., 2016). The use of
collaborative care models in patients with depression and T2DM has been proven effective in
enhancing outcomes, thus illustrating the utility of this integrated approach within PCMHs.
Evidence-based leadership skills, design, implementation, and evaluation of integrated care
within PCMHs
Outstanding leadership is indispensable for a program aimed at integrating healthcare focusing
on depression and Type 2 Diabetes Mellitus (T2DM) within patient–centred medical homes
(PCMHs) to be successful. Working closely with the design team as a leader demands the
ability to collaborate and communicate effectively with multidisciplinary teams. Research implies
that without consensual vision, mutual respect, and clear communication channels among
specialty providers, PCMHs will find it challenging to coordinate care (Mitchell et al., 2015; Sum
et al., 2023). Leaders should have good teamwork abilities, build open communication, resolve
conflicts, and promote teamwork and trust-building. If these skills are missing, the connection
and communication between the different care approaches will be affected, making the
integration of mental health and primary care services within PCMH more difficult (De Brún et
al., 2019). Managers who can create an integrated team from various professionals and who
are able to promote a comprehensive approach to the fully integrated care model are key.
Aside from that, transforming integrated care models via patient-centred medical homes
(PCMHs) calls for skilled leaders who can manage change and thrive despite systemic and
organisational challenges. Leaders facilitating this process are to provide vision, communicate it
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to all the stakeholders, and build an environment conducive to innovations and continuous
improvement (Wojciechowski et al., 2016; Sum et al., 2023). Lewin's Three-Step Model for
Change provides a valuable framework: "unfreezing" (defrosting awareness and readiness),
"moving" (actualising change and taking actions), and "refreezing" (stabilising and maintaining
change) (Lewin, 1951; Wojciechowski et al., 2016). Lack of proper change management can
cause any integrated care model in PCMHs to become blocked by resistance and eventually not
take root in the healthcare system. Managers who can direct their teams through the change
processes necessary for new care delivery creation are of utmost importance for a successful
outcome.
Also, leaders must have skills in using data collection and research to guide decision-making
and determine the efficacy of care coordination in PCMHs. Strategies could include developing
robust data collection systems, performance indicator monitoring, and routine evaluations to
record changes in patient outcomes and hospital utilisation rates (Brown et al., 2021; Coventry
et al., 2015; Peterson et al., 2020). Converting evidence into practice and adapting interventions
to meet organisational as well as patient population-specific requirements are essential. Data for
decision-making and continuous assessments can help integrated care models in PCMH to
achieve their intended goals or be modified, according to this study (Harvey et al.,
2020). Effective leaders should take advantage of evidence-based practices and regular data
collection to make service delivery changes over time.
Effective leadership in integrated care within the PCMH system cannot be achieved without
including and empowering patients and families as partners in the care. Managers should take a
patient-oriented approach that considers various aspects, such as preferences, needs, and life
situations of people suffering from T2DM and depression (Castañeda et al., 2022; Bowdoin et
al., 2016). This can be done through collective decision-making, culturally competent care,
adequate resources, and patient assistance. With no empowered patients and engagement,
integrated care models based on PCMHs will probably not deliver care properly to patients with
various conditions. Effective leaders will give first preference to patients' perspectives and try to
provide customised services to meet the needs of the local population.
In addition, the evidence emphasises certain leadership styles and competencies that are useful
for integrated care models within PCMHs in terms of their design, implementation, and
evaluation. Among the different leadership styles in a multicultural healthcare environment
where professionals with different backgrounds work together, transformational leadership is the
most effective; this type of leadership focuses on inspiring and motivating others to take part in
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a shared vision (Melnyk & Raderstorf, 2019; Sum et al., 2023). Transformational leadership is
positively connected with job satisfaction among nurses, lower staff turnover, and higher team
performance (Kaiser, 2017; Hu et al., 2016). Real leadership that is defined by transparency,
honesty, and strong relationships can create an atmosphere that supports trust and open
communication, which is needed for comprehensive interprofessional collaboration (Alilyyani,
2022; Peterson et al., 2020). Servant leadership, a paradigm that focuses on followers' needs,
is an appropriate approach in integrated care institutions within PCMHs (Canavesi and Minelli,
2022).
The Benefits of the Proposed Integration for Patients / Service Users
The co-located mental health services within the patient-centred medical homes (PCMHs)
model for adults with T2DM and depression have been proven to be an effective method of
improving patient health and healthcare outcomes. This model illustrates the reciprocal nature
of T2DM and depression, revealing that each issue tends to make the other worse. In the study
of Brown et al. (2021) and Coventry et al. (2015), the incidence of depression among patients
with T2DM was in the range of 15-30%. Even though depression can be risky to develop T2DM
due to unhealthy lifestyles, medication side effects, and physiological changes (Brown et al.,
2021), it is still a serious condition. The integrated approach within PCMHs is built to deal with
the complexity of T2DM and depression, recognising patients' overall well-being through
interventions that enable improved outcomes.
The PCMH model that is being proposed includes mental health care services in primary care
facilities. This intervention allows early and timely detection, identification, and management of
depression among patients with T2DM and, consequently, protects the patients' diabetes
management from being affected by untreated depression. Untreated depression may lead to
undesired outcomes, including poor glycaemic control, varying rates of medication adherence,
and varying degrees of self-care (Castañeda et al., 2022; Coventry et al., 2015). On the other
hand, primary care medical home arrangement enhances the possibility of people attending
mental health services rather than separate mental health facilities (Brown et al., 2021;
Castañeda et al., 2022). This is highly relevant for those people who are seeking to be treated
for a mental health problem because of stigma, limited awareness, or the difficulty in looking for
mental health services apart from hospital visits. This model within PCMHs will make it possible
to eliminate the problem of poor care for this group of people, thus improving mental health care
access.
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Through the utilisation of the best available evidence from randomised controlled trials and
systematic reviews, patients with diabetes and depression can be fully assured of the top
practice that can lead to better physical and mental health outcomes. For example, the LUNA-D
randomised controlled trial results showed a considerable reduction in anxiety and depression
symptoms among Hispanics with T2DM who received the intervention compared to those who
received routine care (Castañeda et al., 2022). Moreover, the COINCIDE trial, which was a
cluster randomised controlled study led in the UK, found that having a collaborative model of
integrated care for patients with diabetes and depression or cardiovascular disease improved
depression symptoms, anxiety levels, self-management skills, and better glycaemic control
(Coventry et al., 2015). These practices have formed the backbone of showing the effectiveness
of integrated care models in dealing with mental health issues and reducing blood glucose
levels, which has opened the doors for wider usage of similar approaches within PCMHs.
PCMHs integrate not only with the aim of improving mental health outcomes but also to promote
physical health outcomes and facilitating self-management behaviours. In reality, people who
manage their mental health more effectively will likely practice a daily self-care routine and have
a balanced lifestyle. This intervention reduces the risk of diabetes-related complications, such
as abnormal glycaemic control (Castañeda et al., 2022; Coventry et al., 2015; Peterson et al.,
2020). In addition to integrated care models within PCMHs, research in this area found that
such models improve patient satisfaction, more seamless continuum of care, enhanced
professional collaboration, and better control of complex conditions for patients with several
needs (Brown et al., 2021; Bowdoin et al., 2016). Consequently, the purpose of the suggested
integration model within PCMHs is to implement a multi-modal, comprehensive, and patientcentred strategy for treating patients suffering from T2DM along with depression.
Secondly, the PCMH models that are integrated within the care system have shown increased
therapy and self-care compliance, as they address both the physical and psychological aspects
of health at the same time. Wang et al. (2022) performed a systematic review with metaanalysis to evaluate the efficiency of integrated care models in improving the physical and
mental health status of diabetes and depression patients. This multidimensional care approach
is something we need to embrace, with studies showing that integrated care models are
effective in attaining both physical and mental health outcomes and the overall well-being of the
patient (Sum et al., 2023).
As a result, the patients have a better quality of life because the integrated system enables
them to have well-managed symptoms, stress levels, and functional abilities (Wang et al., 2022;
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Wong and Mehat, 2020). The proposed integration of PCC within PCMHs is in line with the
principles of patient-centred care, which has tools for autonomy, self-determination, and shared
decision-making. Improved patient health is likely to result from this method's increased patient
involvement, treatment plan compliance, satisfaction, and high medication compliance rates
(Bowdoin et al., 2016; Peterson et al., 2020). In addition, the described integration model may
facilitate better PCMH performance by utilising the previously mentioned strategies.
Moreover, integrating therapy for depressive disorder and type 2 diabetes care within the PCMH
would reduce costs associated with managing complications, hospitalisations, and specialised
care (Wang et al., 2023; Wong & Mehta, 2020). Integrated care within the PCP promotes mental
health, glycaemic control, and adherence to treatment that contribute to reducing the risk of
disease progression for chronic diseases, including cardiovascular diseases, nephropathy, and
neuropathy (Huang et al., 2013; Wang et al., 2023). Effective co-morbidity management can
ensure a decrease in the number of hospitalisations and emergency visits and help contain the
costs of healthcare (Katon et al., 2010; Sum et al., 2023). This goal is in line with the general
aims of healthcare sustainability and cost-effectiveness in addition to being complementary to
the envisaged integration within PCMHs. The notion behind these additional benefits shows
how integrated models within PCMHs can ameliorate patient outcomes and increase the
sustainability and efficiency of the healthcare system.
How Service Users and All Stakeholders Will be Involved
Most of the evidence supporting the Chronic Care Model (CCM) within patient-centred medical
homes (PCMHs) has been collected from studies carried out in high-income countries, while the
effectiveness of CCM in low- and middle-income countries is also being affirmed through
emerging research (Wang et al., 2023; Lastretti et al., 2021). Nonetheless, the effectiveness of
the integrated care of T2DM and depression within PCMHs hinges on the participation of all the
stakeholders, starting with the design phase and continuing through implementation and
evaluation.
The involvement of service users and stakeholders in the development, delivery, and evaluation
of integrated health service within the PCMH model is of vital importance towards achieving this
model, sustainability, and patient centring. The evidence shows several important points on this
topic. First and foremost, patients with T2DM and depression must be engaged in the building of
the integrated care model of the PCMH, which will take of their values, choices, and interests
(Melnyk & Fineout-Overholt, 2019; Katon et al., 2010; Peterson et al., 2020). This can be
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achieved by engaging patients in focus groups, interviews, or surveys to capture and
incorporate their views into the service delivery process.
On the other hand, beyond the patient, members of the family and the caregivers also make up
a pivotal role in supporting individuals with chronic conditions, and they must be integrated into
the care process within PCMHs (Isaacs and Mitchell, 2024; Wang et al., 2023; Bowdoin et al.,
2016). This can be done through educating caregivers on how to manage diabetes and
depression, making sure they have access to the necessary resources and their full
participation in the decision-making process. Identifying and addressing the caregiver's needs
will maintain a comprehensive and supportive environment for the patients within the PCMHs.
The rollout of the integrated care model in PCMHs is conditioned by the collaboration and
endorsement of many healthcare professionals, such as primary care providers, psychologists,
diabetes educators, and allied health professionals (Wojciechowski et al., 2016; Melnyk &
Raderstorf, 2019; Sum et al., 2023). Frequent interprofessional meetings, training programs,
and dedicated communication channels would enable a collaborative work process and
eliminate the information gaps of each stakeholder involved in the integrated care delivery at the
PCMHs. We adopt this multidisciplinary approach to tackle the multifaceted problems among
comorbid patients.
The PCMHs (Isaacs & Mitchell, 2024; Wang et al., 2023; Peterson et al., 2020) can be elevated
through the integration of community agencies, support groups, and local services. Community
partners may assist patients by offering extra support, education, and engagement. Such
integration is important for holistic care service delivery. Local resources and existing networks
will be employed to integrate the integrated care model within PCMHs into the communityoriented environment. The model can also be further refined to meet the specific needs of the
target population group.
It is important to have continuous evaluation and feedback mechanisms that should evaluate
the performance, acceptability, and sustainability of integrated care service delivery within
PCMHs (Melnyk & Fineout-Overholt, 2019; Lastretti et al., 2021; Sum et al., 2023). This can be
done by conducting patient satisfaction surveys, clinical outcome measures, focus groups, or
stakeholder feedback that will be used to improve services and readjustment to meet the current
needs of service users. Implementing constant monitoring and feedback loops ensures that the
team-based approach of PCMH remains dynamic and responds quickly to patients and
healthcare providers' ever-changing needs.
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The research data indicates that service users and their families must be included in the
process, from the initial design to implementation and assessment. Through shared decisionmaking, providers can develop tailored and relevant care plans that align with the patients'
choices based on their values and unique health needs (Melnyk and Fineout-Overholt, 2019;
Bowdoin et al., 2016). The patients, through such an approach, are not only encouraged to be
autonomous and self-determined, but they also are encouraged to be compliant and satisfied
with the care that has been received.
Also, those who are users of services should partake in the process so that barriers, challenges,
and facilitating factors are identified for better implementation. Such experiences and ideas can
be used to decide where and how these integrated care models need change. This can help
transform PCMHs into a patient-centric culture. (Kalra et al., 2018; Lastretti et al., 2021;
Peterson et al., 2020). The service users should be directly involved in evaluating the obstacles
and facilitators of integrated care within PCMHs. The system needs to become more responsive
to the changing needs and situations of the population. Engaging patients will create higher
acceptance and successful integration of integrated services within the PCMHs.
Accordingly, the model for joining mental health care and PCMHs for adults with diabetes and
depression is developed through the partnership of service users and their stakeholders in the
designing, implementation, and appraisal phases. This approach will enable the model to be
adapted to the peculiarities of a particular region or its population. As a result, the model will
become more acceptable and sustainable within any PCMH there. Moreover, integrated
healthcare partnerships within PCMHs become the source of not only reliability but also
effectiveness, patient-centredness, and empowerment, as well as better healthcare outcomes
for individuals with T2DM and depression (Sum et al., 2023; Bowdoin et al., 2016).
Conclusion
The integration of mental health care services within patient-centred medical homes (PCMHs)
for adults with T2DM and comorbid depression shows how multifaceted it can be to link these
conditions. There is no denial that the incorporation of cognitive-behavioural therapy or CBT
within PCMH should be on the front burner, given the high prevalence of depression among
T2DM patients and the significant effect it has on health outcomes and the quality of life. The
leadership competencies, like transformational leadership, change management, and
interprofessional collaboration, are crucial as these models are adopted within PCMHs. This
integration of PCMHs is a powerful ally, offering benefits such as improved mental health, better
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glycaemic control, more treatment adherence, fewer complications, and better quality of life for
patients with multiple needs.
Successful implementation within PCMHs requires several steps: participation in
transformational, servant, and authentic leadership training; enhancement of multidisciplinary
teamwork by establishing linkages; mastering change management skills such as Lewin's
Three-Step Model to overcome organisational barriers; and embracing patient-centredness by
incorporating service users, caregivers, and stakeholders. By tackling these issues, integrated
care models within PCMHs can bring about better patient experiences, health outcomes, and
the sustainability of healthcare systems. Overall, this proposed integration into PCMH serves as
a logical argument; it will cater to the patient's complex needs while enhancing the sustainability
and efficiency of healthcare systems.
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Reference List
Alilyyani B (2022) The effect of authentic leadership on nurses' trust in managers and job
performance: A cross-sectional study, Nursing Reports, 12(4), pp. 993–1003.
Basiri R, Seidu B and Rudich M (2023) Exploring the interrelationships between diabetes,
nutrition, anxiety, and depression: Implications for treatment and prevention strategies,
Nutrients, 15(19), p. 4226.
Bowdoin J J, Rodriguez-Monguio R, Puleo E, Keller D and Roche J (2016) Associations
between the patient-centered medical home and preventive care and healthcare quality for nonelderly adults with mental illness: A surveillance study analysis, BMC Health Services Research,
16(1), p. 434.
Brown M, Moore C A, MacGregor J and Lucey J R (2021) Primary care and mental health:
Overview of integrated care models, The Journal for Nurse Practitioners, 17(1), pp. 10–
14.
Canavesi A and Minelli E (2022) Servant leadership: A systematic literature review and
network analysis, Employee Responsibilities and Rights Journal, 34(3), pp. 267–289.
Castañeda S F, Gallo L C, Garcia M L, Mendoza P M, Gutierrez A P, Lopez-Gurrola M,
Roesch S, Pichardo M S, Muñoz F and Talavera G A (2022) Effectiveness of an
integrated primary care intervention in improving psychosocial outcomes among Latino
adults with diabetes: the LUNA-D study, Translational Behavioral Medicine, 12(8), pp.
825–833.
Coventry P, Lovell K, Dickens C, Bower P, Chew-Graham C, McElvenny D, Hann M,
Cherrington A, Garrett C, Gibbons C J, Baguley C, Roughley K, Adeyemi I, Reeves D,
Waheed W and Gask L (2015) Integrated primary care for patients with mental and
physical multimorbidity: Cluster randomised controlled trial of collaborative care for
patients with depression comorbid with diabetes or cardiovascular disease, BMJ,
350(feb16 3), pp. h638–h638.
11 | P a g e
De Brún A, O'Donovan R and McAuliffe E (2019) Interventions to develop collectivistic
leadership in healthcare settings: A systematic review, BMC Health Services Research,
19(1), p. 72.
Haldane V, Chuah F L H, Srivastava A, Singh S R, Koh G C H, Seng C K and LegidoQuigley
H
(2019)
Community
participation
in
health
services
development,
implementation, and evaluation: A systematic review of empowerment, health,
community, and process outcomes, PLOS ONE. Edited by C Maulsby, 14(5), p.
e0216112.
Harvey G, Kelly J, Kitson A, Thornton K and Owen V (2020) Leadership for evidencebased practice—Enforcing or enabling implementation? Collegian, 27(1), pp. 57–62.
Hu Y-Y, Parker S H, Lipsitz S R, Arriaga A F, Peyre S E, Corso K A, Roth E M, Yule S J
and Greenberg C C (2016) Surgeons' leadership styles and team behaviour in the
operating room, Journal of the American College of Surgeons, 222(1), pp. 41–51.
Isaacs A N and Mitchell E K L (2024) Mental health integrated care models in primary
care and factors that contribute to their effective implementation: A scoping review,
International Journal of Mental Health Systems, 18(1), p. 5.
Kaiser J A (2017) The relationship between leadership style and nurse-to-nurse incivility:
Turning the lens inward, Journal of Nursing Management, 25(2), pp. 110–118.
Kalra S, Jena B and Yeravdekar R (2018) Emotional and psychological needs of people
with diabetes, Indian Journal of Endocrinology and Metabolism, 22(5), pp. 696–704.
Lastretti M, Tomai M, Visalli N, Chiaramonte F, Tambelli R and Lauriola M (2021) An
integrated medical-psychological approach in the routine care of patients with type 2
diabetes: A pilot study to explore the clinical and economic sustainability of the healthcare
intervention, Sustainability, 13(23), p. 13182.
Melnyk B M and Raderstorf T (2019) 'Making the case for evidence-based leadership and
innovation', in Melnyk B M and Raderstorf T (eds.) Evidence-Based Leadership,
12 | P a g e
Innovation, and Entrepreneurship in Nursing and Healthcare. 1st edn. New York, NY:
Springer Publishing Company.
Mitchell R, Boyle B, Parker V, Giles M, Chiang V and Joyce P (2015) Managing
inclusiveness and diversity in teams: How leader inclusiveness affects performance
through status and team identity, Human Resource Management, 54(2), pp. 217–239.
Peterson K A, Carlin C, Solberg L I, Jacobsen R, Kriel T and Eder M (2020) Redesigning
primary care to improve diabetes outcomes (the united study), Diabetes Care, 43(3), pp. 549–
555.
Semenkovich K, Brown M E, Svrakic D M and Lustman P J (2015) Depression in type 2
diabetes mellitus: Prevalence, impact, and treatment, Drugs, 75(6), pp. 577–587.
Steinmann B, Klug H J P and Maier G W (2018) The path is the goal: How
transformational leaders enhance followers' job attitudes and proactive behaviour,
Frontiers in Psychology, 9, p. 2338.
Sum G, Sim S Y H, Chay J, Ho S H, Ginting M L, Lim Z Z B, Yoong J and Wong C H (2023) An
integrated patient-centred medical home (PCMH) care model reduces prospective healthcare
utilisation for community-dwelling older adults with complex needs: A matched observational
study in Singapore, International Journal of Environmental Research and Public Health, 20(19),
p. 6848.
Udedi M, Pence B W, Stewart R C and Muula A S (2020) Detection and prevalence of
depression among adult type 2 diabetes mellitus patients attending non-communicable
diseases clinics in Lilongwe, Malawi, International Journal of Mental Health Systems,
14(1), p. 79.
Wang Y, Guo D, Wang M, Hu M, Zhu D, Yu Q, Li Z, Zhang X, Ding R, Zhao M and He P
(2023) Community-based integrated care for patients with diabetes and depression (CICPDD): Study protocol for a cluster randomized controlled trial, Trials, 24(1), p. 550.
Wang Y, Hu M, Zhu D, Ding R and He P (2022) Effectiveness of collaborative care for
depression and HbA1c in patients with depression and diabetes: A systematic review and
meta-analysis, International Journal of Integrated Care, 22(3), p. 12.
13 | P a g e
Wojciechowski E, Pearsall T, Murphy P and French E (2016) A case review: Integrating
Lewin's theory with Lean's system approach for change, OJIN: The Online Journal of
Issues in Nursing, 21(2). doi.org/10.3912/OJIN.Vol21No02Man04.
Wong J and Mehta G (2020) Efficacy of depression management in an integrated
psychiatric-diabetes education clinic for comorbid depression and diabetes mellitus types
1 and 2, Canadian Journal of Diabetes, 44(6), pp. 455–460.
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Appendix: Table showing how the integration of mental health care and patient-centred
medical homes (PCMHs) for adults with Type 2 Diabetes (T2DM) and comorbid depression
could be realised
Key Component
Description
Patient-Centred Care
The PCMH model emphasizes delivering comprehensive,
Delivery
coordinated, and person-centred care to patients. For adults with
T2DM and comorbid depression, this means:
- Creating an individualized, holistic care plan that addresses both
physical and mental health needs concurrently
- Involving patients and caregivers as partners in shared decisionmaking about their treatment
- Providing self-management education and support for T2DM,
depression, and lifestyle changes
- Offering culturally and linguistically appropriate services tailored to
patient preferences
- Facilitating open communication among the patient, family, and
care team members
Integrated Care Team
A multidisciplinary, integrated care team collaborates to provide
whole-person care. The team may include:
- Primary care providers (physicians, nurse practitioners, physician
assistants)
- Endocrinologists or diabetologists
- Mental health professionals (psychologists, therapists, psychiatric
nurses)
- Certified diabetes care and education specialists
- Registered dietitians/nutritionists
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- Social workers
- Health coaches
- Pharmacists
- Community health workers
The integrated team develops a cohesive treatment plan, coordinates
care across different settings/providers, and meets regularly (inperson or virtually) to discuss patient cases and adjust the care plan
as needed.
Comprehensive
Screening &
Monitoring
All patients receive comprehensive screening for:
- Depression using a validated tool (e.g. PHQ-9) at regular intervals
and after major health events
- Diabetes distress and other mental health conditions
- Social determinants that impact health (food/housing insecurity,
transportation, etc.)
- Close monitoring of physiological measures (A1C, blood pressure,
BMI, etc.) and treatment adherence
Evidence-Based Care
Treatment for T2DM and depression follows evidence-based clinical
guidelines and best practices, including:
- Use of stepped care therapy and treatment algorithms
- Psychotherapy (e.g. cognitive behavioural therapy, behavioural
activation, problem-solving treatment)
- Pharmacotherapy (antidepressants, antidiabetic medications) as
appropriate
- Integration of diabetes self-management education and behavioural
counselling
- Medical nutrition therapy and healthy lifestyle promotion
Coordinated Care
Delivery
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Care is coordinated and information is shared seamlessly among
different providers using an integrated electronic health record
system and secure messaging. Key elements include:
- Warm handoffs between primary care and mental health providers
- Collaborative treatment planning
- Follow-up monitoring and adjustment of the care plan as needed
- Care management and navigation support (in person or via
telehealth)
- Referral management and tracking of external referrals
Enhanced Access
The PCMH facilitates enhanced access to care through:
- Extended evening/weekend hours for appointments
- 24/7 clinical advice by telephone or telehealth access
- Shorter waiting times for routine and urgent appointments
- Access to educational resources and group visits
- Facilitated referrals and connections to community
services/resources
- Home-based care, mobile integrated health services for
homebound patients
Quality Improvement
Continuous quality improvement processes are employed, utilizing:
- Registry tools to track process and outcome metrics
- Routine team meetings to review quality data and metrics
- Evidence-based clinical decision support built into EHR
- Patient experience surveys and focus groups
- Plan-Do-Study-Act (PDSA) rapid cycle improvement projects
- Learning collaboratives across multiple PCMH sites
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Practice
Successfully implementing the integrated PCMH model requires
Transformation
practice transformation through:
- Clinical leadership and change management
- Workforce training and education
- Clinical decision support within the EHR
- Enhanced team-based care delivery and communication
- Data-driven performance management and accountability
- Alignment of payment models and financial incentives
Patient Engagement
Engaging patients as partners and promoting effective self-
& Self-Management
management through:
- Motivational interviewing and goal-setting
- Self-monitoring of symptoms, glucose levels, etc.
- Use of patient portals, mobile apps and remote monitoring
- Virtual group classes and peer support groups
- Connections to community resources and social services
Population Health
Management
Using a population health approach by:
- Risk stratifying the patient panel
- Targeted outreach to high-risk patients
- Panel management to ensure all patients receive appropriate
services
- Addressing social determinants through community partnerships
- Public health coordination and community-based prevention efforts
The fundamental elements required to combine mental health services with the patientcentred medical home model for persons with Type 2 diabetes and co-occurring
depression are displayed in this table. In order to rethink care delivery, increase
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accessibility, implement a team-based integrated care system, apply evidence-based
care, include patients, and improve quality through continuous improvement initiatives, it
sets out the overall leadership of practice level reforms. Through workforce training,
data-driven performance management, leadership, and payment model alignment, the
model envisions a change of practice. Together with these, the table highlights other
important factors that are necessary to achieve care coordination, such better referrals,
access, communication, and care transitions between various venues and providers.
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