NSG/506 Week 4: Interprofessional Collaboration, sample paper

Three Professions, One Registry: A Family Nurse Practitioner Leading Collaborative Care for Depression in a Rural Primary Care Clinic

[Student Name]

University of Phoenix

NSG/506: Transition to Advanced Practice Nursing

Week 4 Assignment

[Instructor Name]

[Date]

The clinic, team and patients are a composite written for a model paper.

In a composite rural county, the nearest psychiatrist accepting new patients is a 90-minute drive away, and the wait is four months. A family nurse practitioner (FNP) at the county's only primary care clinic found that about one in eight adults she saw screened positive for depression on the PHQ-9, and most never reached specialty care. She was already prescribing antidepressants, but without regular follow-up many patients stopped their medication within weeks or stayed on a dose that was not working. The problem was not that no one knew how to treat depression; it was that no one was responsible for noticing when treatment was not working. This paper describes how the FNP led the creation of a collaborative care team and examines the interprofessional collaboration that made it work.

The Evidence for Collaborative Care

Collaborative care organizes treatment around a team rather than a single clinician. In the landmark IMPACT trial, Unutzer et al. (2002) randomized older adults with depression in primary care clinics to collaborative care, led by a depression care manager working with the primary care provider and a consulting psychiatrist, or to usual care. At twelve months, patients in collaborative care had substantially higher rates of treatment response and greater satisfaction than those in usual care. Archer et al. (2012), in a Cochrane review of 79 randomized trials, found that collaborative care was associated with significant improvement in depression and anxiety outcomes compared with usual care in the short and medium term.

The evidence matters for collaboration because it shows that the benefit comes from how the professions work together, not from a new treatment. The medications and psychotherapy are the same ones available in usual care; the difference is structure and shared responsibility.

Roles on the Team

The national interprofessional competencies are organized under values and ethics, roles and responsibilities, communication and teams and teamwork (Interprofessional Education Collaborative [IPEC], 2023). Clarity of roles was the first task.

The FNP remains the treating clinician. She diagnoses depression, prescribes and adjusts medication, manages medical conditions that affect mood and holds overall responsibility for each patient's care.

The behavioral health care manager, a licensed clinical social worker hired with grant funding, engages patients after diagnosis, measures symptoms with the PHQ-9 at each contact, provides brief behavioral activation and problem-solving therapy, follows up by phone or in person at least monthly and maintains the patient registry.

The consulting psychiatrist, based at a regional center, reviews the registry with the care manager for one hour each week by video, recommends treatment changes for patients who are not improving and is available for direct consultation on complex cases. He rarely sees patients himself.

The patient is also a member of the team, setting goals and deciding among options.

Structures That Carry Collaboration

Good intentions are not enough; collaboration needs structures. Three carry this team's work.

The registry is a shared list of every patient in the program with the date of enrollment, each PHQ-9 score, current treatment and the date of the last contact. It lets the team see the whole population at once and spot patients who are not improving or have fallen out of contact.

The weekly case review is the hour when the care manager and psychiatrist discuss patients flagged on the registry. The care manager then sends the psychiatrist's recommendations to the FNP through the electronic record, and the FNP decides whether to follow them and documents her decision.

The shared care plan, visible to all three professionals, records the patient's goals, the treatment and the target, usually a 50% reduction in PHQ-9 score within twelve weeks, and when treatment will be adjusted if the target is not met.

These structures address the communication competency directly: each profession knows where to find information, when decisions are made and who makes them.

Conflict and Its Resolution

Collaboration was tested three months into the program. The psychiatrist recommended switching a patient's antidepressant after eight weeks with a PHQ-9 score that had barely changed. The FNP disagreed; she knew the patient had missed doses during a family crisis and had only recently begun taking the medication consistently. She also knew from a recent visit that the patient's thyroid level was low, which could affect mood.

The team's structure made the disagreement productive. The FNP documented her reasoning in the shared plan, the care manager raised it at the next review and the psychiatrist agreed to continue the medication for four more weeks while the thyroid was treated, with a clear plan to switch if the score did not improve. The resolution reflected the IPEC values of respect for each profession's expertise and a shared focus on the patient: the psychiatrist brought pharmacologic expertise, the FNP brought knowledge of the patient's medical history and context and the care manager kept the process moving. Four weeks later the patient's score had fallen by half.

Leadership From the Advanced Practice Nurse

The FNP's leadership was essential to starting the program, even though she was not the most specialized member of the team. She gathered clinic data on depression screening and follow-up, wrote the grant proposal that funded the care manager, negotiated the psychiatrist's consulting agreement with the regional center and trained the clinic's medical assistants to administer the PHQ-9 at every adult visit. Advanced practice nurses in rural areas are often the clinicians best placed to lead such programs because they are the ones present every day.

Measuring the Team's Results

The team tracks the percentage of enrolled patients with a follow-up PHQ-9 within 30 days, the percentage who achieve a 50% reduction in score at twelve weeks and the percentage in remission, defined as a score below 5. It also tracks the number of patients reviewed each week and the proportion of psychiatrist recommendations the FNP accepted, which serves as a rough measure of collaboration: very low acceptance would suggest poor communication, and complete acceptance might suggest the FNP was not using her own judgment.

Sustaining the Team

A collaborative team that depends on grant funding and one enthusiastic clinician is fragile. To make the model last, the FNP worked with the clinic's billing staff to use the Medicare and Medicaid billing codes for behavioral health integration and collaborative care services, which pay for the care manager's monthly work and the psychiatric consultation when documentation requirements are met. She also wrote the program's procedures into the clinic's policies, so that a new provider or care manager could step into a role without rebuilding the team from memory. Sustainability is part of interprofessional leadership: a structure that survives the departure of any single member is the clearest sign that collaboration has become the way the clinic works.

Conclusion

Collaborative care for depression shows that interprofessional collaboration can be the difference between treatment that works and treatment that stalls. In a rural clinic, a family nurse practitioner led the creation of a team in which a care manager tracked every patient and a distant psychiatrist reviewed the registry weekly, with clear roles, shared structures and a respectful way to handle disagreement. The evidence behind the model and the team's own measures show why the advanced practice nurse's role in building such teams is as important as her role in treating patients.

References

Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., Dickens, C., & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, 2012(10), Article CD006525. https://doi.org/10.1002/14651858.CD006525.pub2

Interprofessional Education Collaborative. (2023). IPEC core competencies for interprofessional collaborative practice: Version 3. https://www.ipecollaborative.org/ipec-core-competencies

Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr., Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noel, P. H., Lin, E. H. B., Arean, 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