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
