NCOAs Center for Healthy Aging

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NCOAs Center for Healthy Aging

• The Center for Healthy Aging, a division of the
  National Council on Aging, works to foster
  innovative work that promotes healthy aging, 
  encourages and assists state level and
  community-based organizations serving older
  adults to develop and implement evidence-based
  programs on
• health promotion
• disease prevention
• chronic disease self-management

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NCOAs Center for Healthy Aging

• Works to develop, resources, tools, trainings and
  identifying best practices
• Collaborate with diverse organizations to
  contribute to a broad-based national movement
• Identify, translate and disseminate evidence on
  what works scientific studies and best
  practices
• Promote community organizations as essential
  agents for improving the health of older adults
• Advocate for greater support for strong and
  effective community programs

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NCOAs Center for Healthy Aging

• The Center also serves a resource center for the
  Administration on Aging Evidence-Based Disease
  Prevention Grants Program
• Grants in 27 states funded through AoA or
  Atlantic Philanthropies.
• Grants in 8 states funded to develop the
  infrastructure to implement Chronic Disease Self
  Management Program (CDSMP) statewide.
• Develop tools and resources to assist with the
  implementation of EBP programs.
• Promoting the partnership between state
  departments on health and state units on aging.

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HEALTHY IDEAS
Identifying Depression Empowering Activities
for Seniors
Esther Steinberg Nancy Wilson
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Overview

• Depression in Older Adults Caregivers
• Evidence-Based Approaches to Depression
• Healthy IDEAS Overview and Outcomes
• Program Implementation Client and Agency
  Activities

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RAPP and Group Respite Programs Reach High Risk
Elders

• Estimated 40 to 70 of caregivers experience
  clinically significant symptoms of depression.
  25-50 meet criteria for major depression
• Higher levels of clinical depression in
  caregivers of persons with dementia
• Grandparents as caregivers face stressors
  increasing depression risk

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Symptoms of Depression (DSM IV)

• Symptoms persist for two weeks or longer
• Depressed mood or an inability to enjoy life
• Any four of the following seven criteria must be
  present
• Change in sleep
• Change in eating habits
• Low energy or fatigue
• Feeling of worthless or excessive guilty
• Restlessness or slowed-down movements
• Thoughts of death or suicide

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The Problem Depression

• Depression is a recurring, chronic illness.
• Older adults are often under-recognized
  Under-diagnosed older adults underreport and
  present somatically.
• Co-exists with other mental or physical
  illnesses, including dementia and drinking.
• Cultural diversity can affect the presentation of
  depression.

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Impact of Depression

• Depression kills
• Increases risk of death
• Reduces likelihood of successful treatment for
  other medical conditions
• Greatly increases risk of suicide and pain
• Equal or greater level of physical social
  dysfunction than most chronic medical conditions
  commonly recurs

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Barriers to Addressing Depression in Older Adults

• Client Barriers
• Stigma reluctance to acknowledge depression
• Lack of knowledge about depression care
• Provider Barriers
• Lack of knowledge and skills
• Competing demands
• Scarcity of mental health professionals

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Barriers to Addressing Depression in Older Adults

• System Barriers
• Access availability of services
• Lack of financing
• Cannot depend on primary care alone
• Need for intra- and interagency collaborations
  and partnerships

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What we Know

• Health Disparities are significant.
• Proactive Identification of depression is
  critical but not sufficient.
• Effective methods to identify, evaluate, treat
  depression and improve quality of life are
  available.
• Strongest evidence depression care management
  and cognitive behavioral therapy approaches.

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What is Healthy IDEAS?
Healthy IDEAS (Identifying Depression, Empowering
Activities for Seniors)

• An evidence-based community depression program
  designed to detect and reduce the severity of
  depressive symptoms in older adults with chronic
  health conditions and functional limitations
  through existing community based case management
  services.

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Program Goals

• Identify and address depression in older adults.
• Reach the intended population of frail, high-risk
  elders, who are often overlooked and
  under-treated.
• Train agency staff to provide and deliver an
  evidence-based depression intervention.
• Improve the linkage between community aging
  service providers and health care professionals
  through appropriate referrals, better
  communication effective partnerships.
• Prevent recurrence of depression through regular
  ongoing depression screening.

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Healthy IDEAS is an Evidence-based
Program

• Science to Service
• Used an approach translated from specific
  scientific random controlled positive research.
• Combines evidence-based components from other
  depression interventions including these major
  depression studies
• PEARLS AND IMPACT
• Retains the key elements of the programs to
  ensure known evidence-based ingredients remain
  (Fidelity).

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Evidence for Depression Care Management

• IMPACT (Improving Mood-Promoting Access to
  Collaborative Treatment). Unützer, J., Katon,
  W., Callahan, C.M., and J.W. Williams, Jr., et
  al. (2002). Collaborative care management of
  late-life depression in the primary care setting
  A randomized controlled trial. JAMA
  288(22)2836-2845.
• PEARLS (Program to Encourage Active, Rewarding
  Lives for Seniors). Ciechanowski, P., Wagner,
  E., Schmaling, K., Schwarz, S., Williams, B.,
  Diehr, P., Kulzer, J., Gray, S., Collier, C., and
  LoGerfo, J. (2004) 291(13)1569-77.
  Community-integrated home-based depression
  treatment in the elderly A randomized controlled
  trial. Journal of the American Medical
  Association 291(13)1569-77.
• IMPACT AND PEARLS offered the care management
  road map and evidence for in-home approach

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Evidence for Healthy IDEAS Components

• Screening and Assessment Early recognition of
  depression facilitates treatment and can be done
  by non-professionals using valid tools. (Whooley
  et al. 1997, Sheikh Yesavage, 1986, Williams et
  al. 2002.)
• Education about Depression and Self-care
• Referral, Linkage and Follow-up
• (Unützer et al.,2002 and Hunkeler et al.,
  2000.)
• Behavioral Activation Helping clients
  activate to increase behaviors that fit with
  life goals and produce rewards will help decrease
  depressive symptoms. (Hopko et al.,2003,,
  Jacobson et al., 2000.)

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Core Program Components

• Screening assessing severity of depressive
  symptoms
• Two-question screen standardized assessment
• 15 item Geriatric Depression Scale (GDS) or PHQ-9
• Educating older adults family caregivers about
  depression and treatment including self-care
  effective use of medication.
• Referral linkage to health or mental health
  providers.
• Behavioral Activation (BA) empowering older
  adults to manage their depressive symptoms by
  engaging in meaningful, positive activities.

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Behavioral Activation

• Improve mood by
• Increasing frequency of behaviors that lead to
  positive outcomes
• Doing activities that feel good or are
  pleasurable or reduce stress (may involve a task,
  something social or an activity)

           
Rewarding Activities
 
  Decreased Depressive Symptoms
  Improved Mood
        .
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Target Population

• Underserved Populations
• Ethnically diverse and socio-economically diverse
  populations of older adults who are at high risk
  for depressive symptoms and living in the
  community.
• Inclusion Criteria
• 60
• Currently enrolled in a care or case
  management program
• Cognitive ability to participate
• Able to communicate verbally

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Program Design

• Embedded in case management programs.
• Case managers visit clients in their home and do
  telephone follow-up as well in the community
  individually over a 3-6 month period.
• A manual outlines the steps and includes written
  worksheets, client handouts, and forms to support
  and document the steps and client outcomes.
• Community partnership approach for training,
  evaluation fidelity.
• Partner with health mental health care
  providers to facilitate referral.

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Healthy IDEAS Implementation Process Activities
and Resources

• Agencies or Community Partnerships need
• Dedicated program leadership
• Mental/Behavioral Health Expertise for
  Training/Coaching
• Effective Linkage and Communication systems with
  Treatment Providers
• Practitioners who can incorporate components into
  their existing case management routine with
  older adults/caregivers
• System for collecting and monitoring depression
  and other relevant outcome data

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Client Intervention Flowchart
New or Existing Agency Client
Depression Screening Administered Two
Questions
Negative Screen
Positive Screen
Geriatric Depression Scale (15 item)
Administered
Severe Depression
Mild/Moderate Depression
No Depression
Education Offered
Referral to MD or MH specialist
Behavioral Activation Offered
Education Offered
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Delivery Experience and Outcomes

• Older adults vary in their readiness to address
  depression
• Most elders prefer treatment through primary
  care others accept mental health services
• Increased participation in BA associated with
  better outcomes
• Medication Use is common, yet not always
  effective

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Client Impact

• Reduction in depression severity
• Reduction of self-reported pain
• Increased knowledge of how to get help for
  depression.
• Increased level of activity
• knowledge of how to manage
  depressive symptoms.

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GDS Outcomes (15 item scale)
Scores at 3 and 6 months differ from baseline at
p lt .0001
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Clients Reporting Pain
Scores comparing Baseline to 6 months differ at p
lt .005
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Agency Impact

• Staff are trained to deliver an evidence-based
  intervention
• Adds credibility to the work
• Case management services are expanded to include
  mental health
• OK to talk about take action
  on Depression
• I was surprised that my clients
  were not
  only willing to talk about their
  mood but chose to
  do something.
• What seemed like a small step to me
  helped my
  client feel successful

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Community Impact

• Reached under-served populations
• low-income, physically frail, ethnic and
  racial minorities
• Improved linkage between community aging service
  providers and health /mental health professionals
  
• Fostered community academic partnerships
• Helped prevent recurrence of depression

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Miss Grace

• 68 year old single woman, lives with her brother
  who has Alzheimers disease.
• Initial geriatric depression score 8/15
• Client encouraged to do something she enjoys -
  both client her brother were professional
  artists.
• First step spend 30 minutes 1X a week sketching.
  
• Goal increase the time she spent painting
• She now paints or draws almost daily. Her brother
  has also begun drawing again
• Follow-up GDS at 90 days 6/15

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Success!

• 67 year old woman with cerebral palsy, husband of
  45 years is wheelchair bound and suffering from
  early dementia.
• Initial GDS score 13/15 in May
• Behavioral Activation Goals
• Have her hair done at the beauty shop
• See her doctor on a routine schedule
• Follow-up GDS scores 10/15 in August
• Without this encouragement, I would never have
  felt like doing it on my own.

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Keys to Successful Implementation

• Collaboration with community mental health
  experts to assist with
• Training of care managers and supervisors
• Linkages to evaluation and treatment resources
• Organizational Staff Readiness for Change
• Internal advocate/cheerleader
• Training
• Follow-up Coaching and Supervision

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Challenges

• Stigma clients and providers
• Reluctance to change Clients and staff both
  have to learn new behaviors
• Resources Affordable mental health diagnostic
  or treatment services
• Time required for the intervention and competing
  demands
• Commitment at the agency level to addressing
  depression and supporting a change process.

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Healthy IDEAS Replication

• Plan includes approach and tools for each core
  component and stages of implementation
• Technical Assistance
• Program manual role descriptions, scripts,
  fidelity tools
• Training curriculum DVD for skills training
• Training tools and resources from other adopters
• Unlimited email support for implementation
  sustainability
• Tools for assessing organizational readiness
• Consultation regarding evaluation processes
• Resources to support academic-community
  partnership

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Dissemination

• Organizations
• Area Agency on Aging case management programs
• Local non-profit social service agencies
• Behavioral health provider agencies
• Caregiver support programs

• States
• Arizona
• Georgia
• Maryland
• Maine
• Michigan
• New Jersey
• Ohio
• Texas
• Vermont

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Why Use Healthy IDEAS?

• It works! Clients experienced a
  decrease in their depressive symptoms and pain.
• Expanded service Clients at risk for
  under-recognized under-treated depression are
  served.
• Cost effective Uses existing case management
  service staff.
• Healthy IDEAS is an evidence-based intervention.
• Improved quality of life for older adult clients.

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For more information
Esther H. Steinberg esteinberg_at_shelteringarms.org
713-685-6579 Nancy L. Wilson nwilson_at_bcm.edu
Care for Elders www.careforelders.org/healthyideas
NCOA Center for Healthy Aging www.healthyagingpr
ograms.org

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Lessons Outcomes in Print

• Quijano, L.M., Stanley, M.A., Petersen, N.J.,
  Casado, B.L., Steinberg, E.H., Cully, J.A.,
  Wilson, N.L. Healthy IDEAS A depression
  intervention delivered by community-based case
  managers serving older adults. (2007) Journal of
  Applied Gerontology 26139-156.
• Casado, B. L., Quijano, L.M., Stanley, M.A.,
  Cully, J.A., Steinberg, E.H., Wilson, N.L Healthy
  IDEAS Implementation of A Depression Program
  Through Community-Based Case Management. (in
  press) The Gerontologist.
• Replication report NCOA-Center for Healthy Aging
  website http//www.healthyagingprograms.org