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10.4103/jod.jod_56_21 Received: 30-April-2021, Accepted: 23-July-2021, Published: 12-January-2022
Address for correspondence: Mrs. B. Bhavani Sundari, Madras Diabetes Research Foundation, No. 4, Conran Smith Road,
Gopalapuram, Chennai 600086, India.
E-mail: [email protected]
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How to cite this article: Sundari BB, Poongothai S, Anjana RM, Rao D, Tandon N, Sridhar GR, et al. Perspectives from training the care coordinators—A new cadre to support team‑based diabetes and depression care in India: INDEPENDENT study. J Diabetol 2021;12:480‑91.
Perspectives From Training the Care Coordinators—a New Cadre to Support Team-based Diabetes and Depression Care in
India: INDEPENDENT Study
Balasundaram Bhavani Sundari1, Subramani Poongothai1, Ranjit Mohan Anjana1, Deepa Rao2, Nikhil Tandon3, Gumpeny R. Sridhar4, Aravind R. Sosale5, Radha Shankar1, Rajesh Sagar3, Mohammed K. Ali6, Viswanathan Mohan1, Lydia Chwastiak2
1Madras Diabetes Research Foundation, Chennai, Tamil Nadu, 2University of Washington, Seattle, Washington, USA, 3All India Institute of Medical Sciences, Delhi, India, 4Endocrine and Diabetes Centre, Visakhapatnam, Andhra Pradesh, India, 5Diabetes Care and Research Centre, Bangalore, Karnataka, India, 6Emory University,
Atlanta, Georgia, USA
Abstract
Purpose: Comorbid depression and type 2 diabetes are associated with poor glycemic control, increased complications, and poor self‑
management, compared to either condition alone. The Integrating Depression and Diabetes Treatment (INDEPENDENT) clinical trial demonstrated the effectiveness of an integrated care model in improving diabetes and depression outcomes, in diabetes‑specialty clinics in India. The INDEPENDENT model used task sharing to address the shortage of mental health professionals in India. Care coordinators (CCs) who were dietitians or counsellors were a key component of this care model. This article details the training and support provided to the CCs during the INDEPENDENT trial. Materials and Methods: CCs were nonphysician and nonpsychiatrist health specialists who supported patients in self‑management of diabetes and depression, helping them set achievable goals and monitored progress. During the clinical trial, the CCs underwent both offsite and on‑site trainings. The trainings equipped them with various lifestyle management tools for self‑care, including one‑on‑one education sessions and motivational interviewing for self‑
monitoring, adherence to medication, diet, exercise regimes, and cessation of smoking, among others. Results: Nine CCs from the four sites were trained effectively during the course of the INDEPENDENT study from 2014 to 2018. Conclusions: Given the paucity of mental health professionals in India, the use of collaborative care and a team of well‑trained CCs may be an effective strategy for the management of comorbid depression and diabetes. This model of care could help fill deficiencies in the delivery of care for comorbidity of depression and diabetes care in India.
Keywords: Care coordinator, collaborative care, comorbid conditions, diabetes and depression, diabetes and mental health, task sharing, training
I
ntroductIonDepression affects more than 300 million individuals globally, causing disability and adding to the global burden of disease. Depression management includes psychotherapy or medications, or both.[1] However less than half of them with depression have access to treatment globally.[2] More than 95% of people with common mental disorders have no access to treatment in India.[3]
Type 2 diabetes mellitus (T2DM)—a chronic, metabolic disorder—is set to increase from a current estimate of 463 to 700 million by 2045.[4] India is estimated to have 77 million with T2DM.[5] Lack of awareness, shortage of healthcare personnel, monitoring equipment, and
Head1=Head2=Head1=Head2/Head1
sometimes even medication is a huge challenge to treat T2DM in India.[6,7]
Depression and T2DM often coexist and are associated with poor outcomes.[8‑10] There is growing evidence regarding the bidirectional and adverse interaction between T2DM and depression.[11,12] Guidelines have been advocated recently by the American Diabetes Association[13] owing to the complexity in treating these comorbidities.[14‑16]
Mental health professionals are preferably needed to address and treat depression. The desired ratio of psychiatrists to population would be about 1:100,000.[17]
The World Health Organization reported that in India, there are only 0.3 psychiatrists and <0.1 psychologists or social workers per 100,000 population[18] and only about 3500 psychiatrists.[19]
Comorbid depression and T2DM need optimal treatment,[10] and when depression is not treated, T2DM and cardiovascular outcomes are compromised.[20]
Considering the existing lacuna in treatment modalities,[14]
it is important to contemplate integrating mental health care into diabetes clinics.[21]
The Integrating Depression and Diabetes Treatment (INDEPENDENT) trial evaluated the effectiveness of a multicomponent, task‑sharing, and collaborative care model that integrated depression care into routine T2DM care, in four diabetes clinics in India.[22,23] The INDEPENDENT care model included regular visits with a care coordinator (CC) to support self‑management and to track outcomes.
CCs who were largely dietitians were a key component of this care model. The CCs were trained to support patients and help them achieve treatment goals. The trainings that the CCs underwent during the conduct of the INDEPENDENT study are enlisted and described here along with the lessons learned during the training for this task‑sharing role.
I
ndependentS
tudy: I
nterventIon, d
eSIgn,
and
c
omponentSThe intervention in this study was based on the four core principles of collaborative care:
1. Person‑centred team‑based treatment. Three new team members to support the physician in the management of T2DM and depression were added—the CC, a consulting psychiatrist, and a senior T2DM physician [Figure 1] of whom the latter two were case review specialists;
2. Measurement‑based care to improve depression treatment and outcomes. The validated Nine‑Item Patient Health Questionnaire (PHQ‑9)[24] was used by CCs at every visit, and treatment was adjusted by the physician based on the outcome;
3. Evidence‑based treatments for T2DM and depression, which were supported by decision support electronic health record (DS‑EHR) and integrated into usual care. CCs were to support the treating physicians using the prompts generated from the DS‑EHR;
4. Treatment‑to‑target approach aligning with measurement‑based care. This involves identification of a treatment target (e.g., PHQ‑9 <5 for depression remission) and regular review of the response to treatment, with timely adjustments for participants, which was closely followed by the CCs. This strategy was supported both by DS‑EHR and regular systematic caseload review meetings as explained below.
The intervention was developed by drawing on the strengths and experiences of collaborative care delivery in the United States (TEAMCare study)[25] and India (Centre for Cardiometabolic Risk Reduction in South Asia trial).[26,27] The former focused on depression and chronic illnesses, whereas the later focussed on cardiovascular diseases and T2DM treatment with no focus on depression. Inputs from formative research[22]
of the INDEPENDENT study were incorporated in the intervention to include culturally relevant interventions.
It suggested 1) to engage families in the treatment process, 2) to provide clear/simple written information, 3) use of non‑jargon verbal explanations, and 4) coaching to help patients cope with stigma would add value when incorporated into the intervention.[22]
INDEPENDENT study intended to optimize outcomes in people with comorbid depression and diabetes.
Totally, 404 participants were randomized in the INDEPENDENT study, of whom 196 participants were randomized in the intervention arm across the four sites.
The methodology of the INDEPENDENT study has been detailed elsewhere.[23]
Figure 1 shows the care providers in the INDEPENDENT study and their roles and responsibilities in the study.
r
eSponSIbIlItIeSandr
oleofthecc
Internationally, nurses are largely preferred in collaborative care studies.[28] Also diabetes educators are largely nurses, followed by dietitians.[29] Hence, dietitians were preferred as CCs in this study, due to the shortage of nurses in India.[30]
The CCs in this trial had one thing in common. They all had little‑to‑no experience in mental health but had worked in diabetes settings. They ranged from early‑ to mid‑
career professionals and were from diverse backgrounds including dietetics and psychology. Each clinic site had at least two CCs, except Vizag which had one, with a total of nine CCs trained for the study. The Chennai site had four people who underwent training.
Table 1 shows the number of CCs trained site‑wise during the INDEPENDENT study from 2014 to 2018. At the Madras Diabetes Research Foundation (MDRF) and the All India Institute of Medical Sciences (AIIMS), dietitians were trained as CCs. At the Diabetes Care and Research Centre (DIACON), a doctor and a trained counsellor were trained, and at the Endocrine and Diabetes Centre (EDC), a psychologist was trained as the CC.
The CCs had two main roles in this study:
1) tasks associated with routine diabetes care management
2) support of patient self‑management, including brief behavioral interventions.
The initial responsibility included rapport building and to assess barriers to care with participants. Subsequently, the CCs were required to a) set achievable and measurable goals for their comorbid conditions, b) encourage participants to increase activities to help improve their
mood, c) help make a connection between behaviors and changes in mood, d) encourage them to take responsibility to intermittently monitor their blood glucose and blood pressure, as advised by their physician, and e) encourage participants to take the prescribed medications regularly.
Participants with uncontrolled blood sugars were provided with a glucometer to encourage self‑monitoring of blood glucose. CCs were trained to be the first point of contact for the participants in the intervention arm of this study.
The CCs had to coordinate “systematic case review meetings” on a regular basis. The DS‑EHR was used during these meetings, which was an important tool to keep them efficient and concise. Depression scores and cardiometabolic parameters were color coded in the DS‑EHR and were to be used as cues. Green indicated that the values were within range, yellow indicated moderate severity, and red colour of these parameters reflected values that required immediate attention and had to be communicated to the physician and psychiatrist.[31]
Depressive scores and cardiometabolic parameters were discussed during the systematic case review meetings. The physician and psychiatrist gave inputs during the case review meeting, which were then communicated to the usual care providers. When the usual care providers agreed with the recommendation, this was then communicated to the participants.
c
omponentS oft
raInIngOn‑site training, coaching, mentoring, and manuals were methods of training for the CCs [Figure 2]. The on‑site Figure 1: Care providers in the Integrating Depression and Diabetes Treatment (INDEPENDENT) study along with their roles and responsibilities in the study. DS-EHR = decision support electronic health record
Table 1: Number of care coordinators trained for the trial
Sites Number of CCs trained
Chennai – MDRF 4
Delhi – AIIMS 2
Vizag – EDC 1
Bengaluru – DIACON 2
Total 9
AIIMS = All India Institute of Medical Sciences, CC = care coordinator, DIACON = Diabetes Care and Research Centre, EDC = Endocrine and Diabetes Centre, MDRF = Madras Diabetes Research Foundation
trainings were conducted at the coordinating centre in Chennai (Madras Diabetes Research Foundation).
Training materials were adapted from the TEAMCare study.[31]
Figure 2 shows the various trainings imparted to the CCs Training and content
The study prelaunch training for all sites was carried out in September 2014. The National and International faculty were from Seattle, Atlanta, Chennai, and Delhi.
The trainers included psychiatrists, diabetologists, psychologists, senior doctors, and nurse diabetic educators. The training sessions aimed to facilitate the CCs to recognize depressive symptoms and enable them to support and manage study participants.
The three‑day training program consisted of interactive sessions, discussions, presentations, lectures, video demonstrations, role‑play practice sessions, brainstorming, and feedback sessions. The CCs were provided with supporting training material. Informal feedback was collected on all three days at the end of the training session.
Contents of the training
The training started with an introduction to the role and responsibilities of CCs.
A comprehensive interactive session on depression was conducted. An intensive session on cultural aspects of depression and stigma regarding mental health in India was addressed. The CCs were also trained on how to address depression to participants’ families.
A session on the PHQ‑9 to monitor depression symptom severity was next. PHQ‑9 is a validated instrument to
measure depressive symptoms and screen for suicidal ideation. In the INDEPENDENT study, scores of 10 and more were used to include participants in the study. If the participant scored 2 or 3 for the suicide ideation question, they were to be referred to a psychiatrist.
“Antidepressants,” their benefits, and importance of medication adherence were discussed. The CCs were given a quick reference of antidepressants. Antidepressants were to be considered when a participant’s PHQ‑9 score showed moderate depressive symptoms (≥14) or when there was evidence of functional impairment. The CCs were to nudge the usual care physicians regarding the same.
The CCs were provided with training related to two evidence‑based brief behavioral interventions for the management of depressive symptoms: “problem‑solving therapy (PST) and behavioral activation (BA).”
PST is a tool to empower participants to come up with a solution to a problem they face. PST is a psychological treatment that helps to effectively manage the negative effects of stressful events that can occur in life. It supports adaptive problem‑solving skills and coping with stressful problems.[32]
In addition, a brief overview of a therapeutic approach that is informed by “motivational interviewing” (MI) was provided. MI is an effective strategy to support health behavior change, which recognizes a patient’s ambivalence to change and seeks to identify and support reasons and motivation to change.[33] A “decisional balance sheet” is a tabular method for representing the pros and cons of different choices and for helping someone decide their actions in a certain circumstance.[34] The CCs were trained to use the decisional balance sheet—a tool to motivate participants.
Figure 2: Training imparted to care coordinators (CCs)
CCs also received training in BA. It is a brief behavioral intervention that is derived from cognitive‑behavioral therapy. BA aims to work with depressed individuals to gradually decrease their avoidance, isolation, and increase their engagement in activities that improve mood.[35] CCs were provided with a flashcard to illustrate how inactivity exacerbates depression and the mechanism of BA to interrupt this cycle and a list of enjoyable activities.
Some tools used in BA are mentioned below:
“Pleasurable activities” (PA) is the clinical term for things that are fun, feel good, or at least distract you from your pain. Lack of interest in activities that they enjoyed before is a typical symptom of depression. Participants were to be encouraged to pick and perform some pleasant/
pleasurable activities to reduce their symptoms of depression. A list of 50 PAs that would be suitable in the Indian context were shortlisted. This list was created and finalized during the on‑site training.
“Feel Bad–Do Less” (BA) was depicted in a flash card. It represented how moods affected actions and was to help participants reflect how their moods were affecting their actions. It was to encourage participants to take actions toward self‑care (Appendix 1).
The sensitive topics of “suicidal ideation, suicide risk”
assessment, and assessment of “risk of harm to self” were discussed at length. Since severe depression can increase the risk of suicidal ideation and attempts, it was important that the CCs were trained to have a systematic approach to assess and manage suicide risk. Forms for assessment of the same were made familiar to the CCs.
“Video demonstrations” were part of the training.
Rapport building and case review video demonstrations from the TEAMCare study were played.
There were “role‑play/mock sessions” on rapport building to initiate behavior modification in participants and also ways to discuss depressive symptoms with participants and their families.
The refresher training, just prior to study initiation, was a repeat of the topics discussed above along with some more information about DS‑EHR.
m
onthlyo
ngoIngS
upport/l
ongItudInalt
raInIng Case review meetingsA template (Appendix 2) was used to capture the participant details and convey them to the case review specialists to maintain consistency in information delivery.
This template captured all the details the specialists would need regarding participants, such that they could give their expert opinion. The CCs received many inputs to handle the mental health of participants and to deal with the culturally relevant issues from the psychiatrist. The case review meetings, which were held regularly, served as
an offline ongoing training. Also, the CCs MI techniques were honed during these meetings.
Peer support
A WhatsApp group served as a support group and helped in continued training. The members were CCs, study managers, and the team from the University of Washington (UW; psychiatrist, psychologist, and nurse educator) who were part of the TEAMCare study. The team from the Emory University (Atlanta) was also part of the group. The CCs could clarify queries here and it served as a continuous electronic training system.
Expert mentoring
Regular webinars with the UW team was part of ongoing training. During webinars, one of the teams from the participating sites would present a case study in the form of a PowerPoint presentation (PPT). PPT template was used to capture participant details that need discussion (Appendix 3). This was followed by peer discussions that supported CCs to handle similar cases in their respective sites. This was also an ongoing training for CCs.
During the conduct of the INDEPENDENT study, a total of 19 webinars were conducted. Webinars and peer support used technology and social media to train CCs during the conduct of the study.
d
IScuSSIonDepressive and anxiety disorders followed by schizophrenia and bipolar disorder are the highest disease burden in India.[36] The need of the hour is to have evidence‑based psychological treatment in low‑resource settings, to reduce the global burden of disease attributable to mental disorders.[37]
Considering the complex nature of T2DM management, coordination among primary care physicians, allied health practitioners, and other specialists is necessary.[38]
However health care providers often do not initiate or intensify therapy appropriately during visits of patients, which is also known as clinical inertia—recognition of the problem but failure to act.[39]
Mendenhall et al.[40] suggested that a health systems approach that incorporates mental health care into T2DM care is necessary to combat these co‑occurring and interactive epidemics.
Comorbid T2DM and depression management can be attained through task sharing or task shifting.[41] Task shifting refers to the involvement of non–mental health specialist to collaborate with health care providers, to provide care.[42] Mental health “nonspecialist” is a person who lacks specialized professional training in fields such as psychology, psychiatry, or clinical social work and may include community health volunteers, peer helpers,
social workers, midwives, auxiliary health staff, teachers, primary care workers, and people without a professional medical or paramedical qualification.[43]
Dovlo[44] described various task shifting scenarios, such as shifting tasks from higher‑ to lower‑skilled health workers.
Task shifting includes creation of new professional or nonprofessional cadres, whereby tasks are shifted from workers with more general training to workers with specific training.[45]
Task shifting has been recognized as being a more impactful form for “improving access to psychological treatment” programmes.[37] This can potentially result in cost and physician time savings without compromising the quality of care or health outcomes for patients.[46,47]
A systematic review of task sharing in low‑ and middle‑
income countries showed significant reduction in depressive scores.[48] Another systematic review showed multicomponent integrated care study lasting at least 12 months reduced glycosylated haemoglobin, systolic blood pressure, diastolic blood pressure, and low density lipoprotein cholesterol levels.[49] Katon et al.[50] have also shown that when intervention is provided to people with comorbid depression and diabetes, participants in the intervention arm had overall improvement in the depressive symptoms and cardiometabolic parameters when compared with the control arm.
Katzelnick et al.[51] had also established that a systematic primary care–based treatment program can substantially increase adequate antidepressant treatment, decrease depression severity, and improve general health status compared with usual care. Unützer et al.[52] also established that at 12 months, a greater percentage (45%) of intervention patients had a reduction in depressive symptoms from baseline compared with that of usual care participants (19%).
The results of the INDEPENDENT study have also been positive. A significantly greater percentage of patients in the intervention group vs. the usual care group met the primary outcome (71.6% vs. 57.4%; risk difference, 16.9% [95% CI, 8.5%–25.2%]) where CCs had played a major role in the intervention.[53] The positive response of intervention has also been established by the outcomes of the INDEPENDENT study.[53]
To understand the trainings required for mental health nonspecialist such that they adequately support and manage comorbid conditions in low‑resource settings is critical. Though there is enough said about task sharing, most articles provide only little description of the background of the interventionists or training they received, and the training procedure is not detailed.
In this study, the CCs went through intensive in‑person training sessions and ongoing coaching during the trial.
As the CCs were considered as the backbone of this study, their trainings were constantly relooked into and improvised during the course of the study. They had a strong support structure in terms of the WhatsApp support group and webinars.
Murthy et al.[54] have briefly described how general health workers could be trained to provide mental health services.
India was one of the first developing countries to adopt the National Mental Health Programme (NMHP) in the year 1982. District Mental Health Programme was started under NMHP with the aim to decentralize mental health services.
Changes in the syllabus of undergraduate and postgraduate education and training of health care professionals who deliver clinical care for patients with T2DM and depression have also been suggested by experts.[14] Papa et al.[55] reviewed two nursing programmes and suggested interdisciplinary training that health professionals should undergo, and a small reference is made to mental health.
Owen et al.[56] have given a framework on developing a new educational paradigm regarding collaborative care and educational experiences. The trainings the CCs have undergone may also be included in the curriculum.
a
reaSforf
uturer
eSearchLack of reliable and valid measures of care providers made it challenging to evaluate the training disseminated to CCs, which is a limitation of the study.
Also a thorough evaluation of the trainings of the CCs was not planned. If the CCs were subjected to a before and after evaluation of the trainings, it would have given a fair idea regarding the impact of the trainings imparted. The training provided to the CCs was time and resource intensive, and it would be good to know whether/
how that could be scaled back so that the intervention could be more widely disseminated. When an elaborate training programme is planned for a study, the assessment for the trainings provided should be studied in the future.
Also burnout among physicians has been established.
A study to understand prevention of burnout among physicians due to task shifting can be studied.
c
oncluSIonSIt has been clearly established that comorbid depression and T2DM have poor outcomes when compared with an individual condition. Management of comorbid T2DM and depression remains a clinical challenge for patients and healthcare professionals. Task sharing/shifting may be the answer to address the outcomes of these bidirectional conditions. The results of the INDEPENDENT study have been positive, where task sharing has been an active component of the intervention provided.[53]
Given the paucity of mental health professionals in India, task shifting and a team of well‑trained CCs may help in providing care and management for comorbid depression and T2DM. This task sharing model may be cost‑effective and help fill deficiencies in the delivery of care for comorbid depression and T2DM. This may help to fill the lacuna of mental health human resource scarcity.
Financial support and sponsorship
This study was funded by the National Institute of Mental Health (grant R01MH100390).
Conflicts of interest
There are no conflicts of interest.
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a
ppendIx1: f
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ad–d
ol
eSSAppendix 1 shows Feel Bad–Do Less—the flash card that represented how moods affected actions. This was one of the tools the CCs were trained to use with participants with comorbid depression and diabetes.
Appendix 2: Template used to present cases to the psychiatrist and diabetologist during case review meetings Patient demographics
Name:
Age: sex:
Height: weight: BMI:
Occupation:
Monthly income: housing (own/rented):
Duration of diabetes Age of onset
Associated illness (details and duration)
Family history (DM, psychiatric disorder, other illness) Current complaints:
Drug allergy/food allergy:
Current medication:
Walking/exercise:
Diet:
Family details (nuclear or joint/household members):
Current disease parameters (provide lab and assessment data) Status (done/not done)
Value if done Remarks Diabetes (HbA1c, %)
Blood pressure (SBP, mm Hg) Cholesterol (LDL, mg/dL) Depression (PHQ‑9)
Psychosocial stressors Yes/no Remarks
Family Financial Housing Occupational Others
Mental health treatment history (any therapy or antidepressant medications; other possible disorders) Social history (family, support, network, hobbies, etc.)
Lifestyle issues (physical activity, smoking diet, substance use amount frequency etc.) Women
Menstrual details Menopause
PHQ score Initial Visit Randomization
Visit
Current Visit 1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
3. Trouble falling or staying asleep or sleeping too much.
4. Feeling tired or having little energy.
5. Poor appetite or overeating.
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down.
7. Trouble concentrating on things, such as reading the newspaper or watching television.
8. Moving or speaking so slowly that other people could have noticed. Or the opposite—
being so fidgety or restless that you have been moving around a lot more than usual.
9. Thoughts that you would be better off dead or of hurting yourself in some way.
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Total score Comments/notes:
Intervention:
Psychiatrist comments:
DBP = diastolic blood pressure, HbA1c = glycosylated haemoglobin, LDL‑c = Low density lipoprotein cholesterol, SBP= systolic blood pressure
a
ppendIx3: t
emplate for caSe Study dIScuSSIon durIng webInarSParticipant ID -ABC
Gender Age Diabetic since
HbA1c of ABC at randomization LDL of ABC
PHQ – 9 score of ABC during randomization
Appendix 2 is the template used to capture each participant’s details to be presented to the specialists, that is, the diabetologist and the psychiatrist, so that they can give their opinion and expert advice.
Interim visit 1
Details of the family Particpants challenges Rapport building efforts Advise rendered
Following Interim visits
Improvements Challenges
Anti depressants
If any were started and how the participant was responding
What worked
Challenges
THANK YOU
This template was used to list the participants’ details to facilitate case study discussion during the Webinars.
This template helped the CCs not to miss the participant details during discussions. These webinars made the CCs more confident to empower the participants of the INDEPENDENT study.
