Innovation summary

Some of the most complex and costly individuals to treat are those who present with co-morbid mental and physical health problems. The goal of TEAMcare is to manage depression, diabetes and coronary health disease in primary care.

TEAMcare trains primary care staff to work in collaborative teams delivering care in person and by phone. Training can also be online. Each patient has a TEAMcare care manager (usually a nurse) who is the conduit between the consultation team, the patient’s primary care provider, and the patient.

The TEAMcare programme:

  • Uses a treat-to-target approach, modifying treatment as needed to ensure improvement in symptoms
  • Teaches patients self-care skills to control illnesses
  • Is delivered in the primary care clinic and by phone
  • Encourages behaviours that enhance quality of life

Impact summary

  • Approximately 3,000 people have received TEAMcare
  • In a randomised control trial, TEAMcare has been shown to improve both medical disease control and depression symptoms1
  • Cost savings of $600-$1,100 USD per patient over 24 months, depending on financing system used at implementation site2

"Working in this capacity has been the highlight of my career. We definitely made an impact and change for the better – which is what we, as health care professionals, are trying to do."


-TEAMcare Care Manager

Innovation details

TEAMcare is an evidence-based, patient-centred approach that enhances the primary care team’s ability to provide optimal care. Using the Chronic Care Model and Collaborative Depression Care Model, TEAMcare provides comprehensive team-based care for diabetes, coronary heart disease, and depression simultaneously.

Team-based service delivery

A TEAMcare group is assembled at the primary care level, comprising:

  • TEAMcare care manager:  Usually a nurse, the care manager is the patient’s primary contact for addressing multiple chronic conditions
  • TEAMcare clinical consultants:  A team of consultants including the care manager, the psychiatrist and the primary care specialist provides weekly review of TEAMcare patients and their progress
  • Clinic champions:  Designated staff offer administrative/managerial support

Ongoing training and support

TEAMcare members receive ongoing training, comprising:

  • Initial 2-day intensive training in the key elements of TEAMcare
  • Follow-up booster trainings (in-person or by webinar)
  • Monthly conference calls to assist with implementation issues

Accessible care

TEAMcare is delivered in the primary care clinic and by phone, and features:

  • A focus on teaching patients self-care skills to control illnesses
  • A treat-to-target approach to care, modifying treatment as needed to ensure improvement in symptoms


Key drivers

  • Strong organizational leadership and buy-in
  • Funding allocated for the care manager role and for systematic case review
  • Strong integration with existing primary care programs, which prevents duplication and enhances augmentation of usual primary care


Developing and refining the key components for teaching TEAMcare was critical to ensure that clinics/systems could be successful in implementing the program. These include:

  • Ensuring that full training was delivered adequately to the intended practitioners
  • Ensuring that booster training was in place to account for attrition and turnover in the workforce
  • Ensuring that assistance was present to assess and address local barriers to implementation
  • Identifying strong leadership and clinical champions in the healthcare organizations
  • Ensuring that sufficient funding was allocated to support the program
  • Ensuring that there was ongoing administrative support


  • TEAMcare continues to be disseminated across North America
  • Implementation is currently being tested in India, with collaborations planned with European countries and Australia
  • Future plans include expanding the scope of TEAMcare to other physical and psychiatric conditions include substance abuse


Training partner

Located at the University of Washington, Training Xchange provides training and implementation services onsite to clinics who utilize TEAMcare.

Delivery partners

Institute for Clinical Systems Improvement (ICSI) in Bloomington, Minnesota (USA) is the lead organization for the demonstration grant consortium in partnership with:

Other sites that are currently using TEAMcare or variations on it include:


The clinics and hospital systems that have adopted the TEAMcare approach fund the initial staff training to learn how to do TEAMcare. Organizational support to shift staff responsibilities is needed for successful implementation.


Evaluation methods

A randomized control trial evaluated the clinical and cost-effectiveness of the TEAMcare model.1-3

Cost of implementation

The estimated cost per patient is $1,224 USD. Within a capitated system, this resulted in a cost savings of about $600 USD per patient over 24 months. In a fee for service system, the cost savings was about $1,100 USD per patient over 24 months.2

Impact details

Approximately 1,400 clients have received TEAMcare thus far. The randomized controlled trial demonstrated:

  • Improved HbA1c, blood pressure, LDL and depression symptoms1
  • Improved quality of life and patient satisfaction in clients with diabetes and depression care1
  • More medication changes to effective dosages or types of medications1
  • Reduction in costs of care2


  1. Von Korff M et al. (2011) Functional outcomes of multi-condition collaborative care and successful ageing: results of a randomized trial. British Medical Journal, 343:d6612.
  2. Katon W et al. (2012) Cost-effectiveness of a multi-condition collaborative care intervention. Archives of General Psychiatry, 69(5): 506-514.
  3. Katon W. et al. (2010) Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine, 363(27): 2611-2620.
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