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Lessons Learned from Using Depression Screening Measures

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Program Leadership: Care for Elders and Baylor ... Un tzer, J., Katon, W., Callahan, C.M., and J.W. Williams, Jr., et al. (2002) ... – PowerPoint PPT presentation

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Title: Lessons Learned from Using Depression Screening Measures


1
Lessons Learned from Using Depression Screening
Measures
  • Nancy L. Wilson, LCSW
  • Department of Medicine-Geriatrics
  • Huffington Center on Aging
  • Houston Center for Quality Care Utilization
    Studies
  • Baylor College of Medicine
  • Care for Elders
  • Houston, TX

2
HEALTHY IDEAS
Identifying Depression Empowering Activities
for Seniors
3
Accomplished through Partnerships
  • Program Leadership Care for Elders and Baylor
  • 80 member Houston-based partnership committed to
    creating solutions to increase access to
    services, improve quality and enhance life for
    older adults and caregivers
  • www.careforelders.org
  • Funders John A. Hartford Foundation,
    Administration on Aging, Robert Wood Johnson,
    SAMHSA
  • Policy Leadership AoA , National Council on
    Aging
  • Academic Expertise Baylor College of Medicine
    and Michael E. DeBakey Veterans Affairs Medical
    Center
  • Community Aging and Mental Health Providers
  • Elders and family caregivers

4
Alixe McNeill, MPAVice President, Program
Development Mental Health Lead / Center for
Healthy Agingalixe.mcneill_at_ncoa.org
  • Chair, National Coalition on Mental Health
    Aging

5
National Council on Aging
  • NCOAs Mission
  • To improve the lives of older Americans.
  • Who We Are
  • NCOA is a non-profit service and advocacy
    organization based in Washington, DC.
  • Visit www.ncoa.org

NCOA Core Values Social and Economic
Justice Respect and Caring Innovation Integrity
and Excellence
6
National Council on Aging
  • What We Do
  • NCOA is a national voice for older adults
    especially those who are vulnerable and
    disadvantaged -- and the community organizations
    that serve them.
  • NCOA brings together non-profit organizations,
    businesses and government to develop creative
    solutions that improve the lives of all older
    adults.
  • NCOA works with thousands of organizations across
    the country to help seniors live independently,
    find jobs and benefits, improve their health,
    live independently and remain active in their
    communities.

7
Todays Presentation
  • Late-Life Depression
  • Rationale for Community Action
  • Origins and Key components of Healthy IDEAS
  • Process of Implementation Funding ,
    Partnerships, Steps
  • Training and Technical Assistance
  • Views from Stakeholders

8
Depression is Common, Costly, Disabling, and
Deadly
  • Depression affects 15-20 of older adults
  • Depression is Disabling
  • 2 cause of disability (WHO)
  • Impact on Self-Care ADLs and IADLs
  • Deadly and Reduced Quality of Life
  • Suicide Elderly at greatest risk
  • Co-morbid illnesses Affected Diabetes, Heart
    Disease
  • Costly
  • Expensive (50-100 higher health care costs)
  • Increased Morbidity, Mortality, Non-adherence,
    recovery

9
  • PUBLIC HEALTH
  • Increase awareness / reduce stigma
  • Eliminate health disparities
  • Improve access to services
  • http//www.cdc.gov/aging/

10
Setting Priorities for Older Adults
  • Improving Access
  • Integration of Mental Health and General Health
    Care
  • Home and Community-based Services
  • Improving Quality
  • Evidence-based Practice Implementation
  • Trained Healthcare Workforce with Expertise in
    Geriatrics

11
Depression
  • Major depression is second only to heart disease
    in the magnitude of disease burden..
  • Mental Health Report of the Surgeon General
  • Loneliness, isolation, limited resources and
    physical disabilities increase the risk of
    depression in older adults.
  • Substance Abuse and Mental Health Among Older
    Americans The State of the Knowledge and Future
    Directions

12
Community agencies reach high-risk, underserved
older adults
PRIOR HISTORY
ILLNESS/ DISABILITY
FEMALE
FAMILY HISTORY
RISK FACTORS
SOCIAL ISOLATION
LOSS
FINANCIAL STRAIN
IMMIGRANTS
13
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.
  • Strong evidence depression care management and
    cognitive behavioral therapy approaches.

14
Barriers to Addressing Depression in Older Adults
  • Client Barriers
  • Stigma Im not crazy! Im not a weak person
  • Lack of knowledge- Its just my diabetes or
    being old What will this pill do?
  • Provider Barriers
  • Lack of knowledge and skills
  • Primary Care faces many competing demands
  • Scarcity of mental health professionals
  • System Barriers
  • How can we get care to the person or the person
    to care?
  • Financing of services is limited and in silos

15
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.

16
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.

17
Evidence-based Programs
  • Outcome focused
  • Track social, mental, physical functional
    changes using objective self reported measures
  • Answers the question Can we do what is known to
    work?
  • Monitors fidelity
  • Moves science to service

18
Anatomy of Evidence-based Programs
  • Has a specific target population
  • Has specific, measurable goal(s)
  • Has a stated reasoning behind it and proven
    benefits
  • Has an organized, well-defined program structure
    and timeframe
  • Specifies staffing needs/skills
  • Specifies tools and resources
  • Builds in program evaluation to measure program
    quality and health outcomes

19
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).

20
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.

21
Evidence for Healthy IDEAS Components
  • IMPACT AND PEARLS offered the care management
    road map and evidence for in-home approach
  • Evidence indicates that home-based mental health
    treatment for older adults is effective in
    improving psychiatric symptoms (Van Citters
    Bartels, S , 2004)
  • 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, Linkage, and Self-management Support
    (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.)

22
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

23
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.

24
Core Program Components
  • Screening for symptoms of depression assessing
    severity
  • Two-question screen standardized assessment
  • 15 item Geriatric Depression Scale (GDS) or PHQ-9
  • Educating older adults family caregivers about
    depression effective treatment including
    self-care medication.
  • Referral, linkage follow-up for older adults
    with untreated depression to health or mental
    health providers.
  • Behavioral Activation (BA) empowering older
    adults to manage their depressive symptoms by
    engaging in meaningful, positive activities.

25
Behavioral Model of Depression
Depression results in behaviors that limit
positive outcomes ? reduced pleasure, reduced
accomplishment
Lowered Mood
Decreased Activity
Decreased Pleasant Activities
26
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
        .
27
Evaluation Design
  • Pre-post impact evaluation data collected.
  • Measures were embedded into agency assessment
    care plan review forms.
  • Data collection occurs according to the routine
    timeline for case management Baseline, 3 months,
    6 months, and for some clients 9 months
    assessment.
  • Outcomes address
  • Depression, pain, social function, social and
    physical activity levels, education/knowledge,
    service use
  • Measured client satisfaction via telephone
    interviews.

28
Client Demographic Profile
p.05, p01, p.001, p.0001
29
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

30
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.

31
GDS Outcomes (15 item scale)
Scores at 3 and 6 months differ from baseline at
p lt .0001
32
Clients Reporting Pain
Scores comparing Baseline to 6 months differ at p
lt .005
33
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

34
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

35
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

36
Where is Healthy IDEAS? 50 Sites
  • States
  • Arizona
  • Florida
  • Georgia
  • Hawaii
  • Iowa
  • Maine
  • Maryland
  • Michigan
  • New Jersey
  • Ohio
  • Texas
  • Vermont
  • Organizations
  • Area Agency on Aging case management programs
  • Local non-profit social service agencies
  • Behavioral health provider agencies
  • Caregiver support programs

37
Maine Experience
  • Lead Elder Independence of Maine
  • - an Area Agency on Aging and home care
    coordination agency
  • Statewide rural and urban
  • Funding OAA Medicaid HCBS Waiver
  • Case Managers BAs, LSWs, RNs
  • Clients Caucasian, education high school or
    less, low-income

38
Fort Worth, Texas Experience
  • Lead Area Agency on Aging of Tarrant County and
    United Way
  • Urban County
  • Collaborative Model with agencies linked -
    Catholic Charities, Meals on Wheels, Senior
    Service, Mental Health Association
  • Funding OAA built into agency financing
  • Case Managers BAs, LSWs
  • Clients African Amer. Hispanic, Caucasian

39
Ohio Experience
  • Lead State Mental Health with Aging and
    Substance Abuse
  • Statewide urban and rural
  • Model Older Ohioans Behavioral Health Network
    leadership local AAAs and county MH partners
  • Funding SAMHSA MH Transformation Funds/
  • mini grants to local AAA agencies
    (Integrated CM for Medicaid and OAA funded
    services )
  • Case Managers BAs, LSWs, RNs
  • Clients African Amer., Hispanic, Caucasian

40
Other Experience
  • Florida
  • Local health foundation
  • 3 lead agencies, 80 minority populations
  • New Jersey
  • State Aging OAA grants to Jewish Family Services,
    Medicaid HCBS waiver, MSWs
  • Hawaii
  • Lifespan Community family service provider to
    Asian and minority populations, BAs,

41
Lessons Learned
  • Various lead and provider agencies
  • Success in urban and rural areas
  • Success with racially and ethnically diverse
    groups many low-income
  • Variety in start-up funding
  • Embed practice for sustainability

42
Steps for Implementation
  • Healthy IDEAS Readiness Assessment
  • Leadership Team Partnership Development
  • Staff Selection
  • Program Installation
  • Pre-Service and In-Service Training
  • Consultation and Coaching
  • Program Evaluation

43
1. Healthy IDEAS Readiness Assessment
  • Online survey from NCOA and Healthy IDEAS
  • Assesses agency capacity and willingness to
    implement Healthy IDEAS by measuring key program
    elements
  • Staffing
  • Partnerships
  • Case Management Practice
  • Record Keeping and Reporting Systems
  • Organizational Culture and Support
  • Program Leadership
  • Innovativeness
  • Evidence-based Experience

44
Readiness Report Grid
Graphic representation of a potential adopter
organizations readiness status in terms of each
critical element of an innovative program
45
2. Leadership Team Partnership Development
  • Healthy IDEAS is an important process of
    organizational change requiring leadership and
    time of 2-6 months.
  • Leaders identify, mobilize and unite strengths of
    expertise in aging and mental health services
    within and outside lead agency
  • Establish partnerships for program collaboration
    and referral

46
3. Staff Selection
  • Leadership and Management
  • With Champion(s)
  • Trainer (s) and Coaches
  • Clinical Consultant
  • Case Managers / Frontline Providers

47
4. Program Installation
  • Plan for embedding Healthy IDEAS into current
    delivery system of case management (or other
    service)
  • Establish policies and procedures for
    implementation
  • Customize tools and forms
  • Arrange for training and technical assistance

48
5. Pre-Service In-Service Training
  • Initial education about depression
  • Interactive training
  • Ongoing coaching / supervision

49
6. Consultation and Coaching
  • Goals
  • 1. Support case managers in developing
    confidence /skills to deliver program
  • 2. Assure adherence and competence to conduct
    program
  • Ideally - Train clinically qualified agency
    supervisors or program director
  • Observe, review records, confer, advise
  • Supervisor evaluates case managers

50
7. Program Evaluation
  • Collaborate in evaluation plan development
  • Insure agency needs are met
  • Use menu to select basic process outcome
    measures to be collected
  • Embed data collection in routine forms, and
    systems
  • Promote Continuous Quality Improvement

51
Challenges
  • Stigma among 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 in the face
    of competing demands
  • Commitment at the agency level to addressing
    depression and supporting a change process.

52
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 and Follow-up Coaching and Supervision

53
Implementation Process Activities and
Resources
  • Agencies or Community Partnerships need
  • Dedicated program leadership Champion,
    Supervisors
  • Mental/Behavioral Health Expertise for
    Training/Coaching
  • Effective Linkage Communication systems with
    Treatment Providers
  • Practitioners with capacity/ability to
    incorporate components into their existing case
    management routine with older adults/caregivers
  • System for collecting and monitoring depression
    and other relevant outcome data

54
Program Implementation
  • Finding Funding
  • Building the Right Team
  • Installing the Program
  • Training
  • Refer to Action Briefs for Reinforcing Details
    and Support PRC-HAN session and Web

55
Healthy IDEAS Replication
  • Tools for assessing organizational readiness
  • Plan includes approach and tools for each core
    component and recognizes stages
  • Training curriculum DVD for skills training 80
    min.
  • Technical assistance model
  • Resources to support needed community partnership
    for replication support

56
Plan includes approach and tools for each core
component and recognizes stages Training tools
and resources that process evaluation lessons
from early adopters Agency and Intervention
Manuals role descriptions, fidelity tools
57
For More Information
  • 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
  • Care for Elders www.careforelders.org/healthyide
    as

58
  • What Do Key Stakeholders Say About Healthy
    IDEAS?

59
Administrators Say
  • We see depression with isolated people.
    Depression is part of the problem stopping
    healthy behavior. If we want to help people
    remain in their own homes with high quality of
    life, we need to address depression and make this
    part of our services.
  • Since we have ongoing training for case managers,
    we could integrate depression care into the
    broader program - it would be great to do this.
  • Before we started Healthy IDEAS, we did not have
    the tools to work with clients on depression, now
    we have a concrete program that we can use to
    truly assist clients.

60
Funders
  • AoA supports Healthy IDEAS in its Evidence-Based
    Disease and Disability Prevention Program
  • SAMHSA gave Healthy IDEAS a Science Service
    Award
  • Federal, state foundation funders set goals
  • Within 10 years, national reach will be achieved
    with effective community depression care programs
    like Healthy IDEAS and PEARLS.
  • Programs will be high quality, have fidelity and
    be implemented in sustainable ways through strong
    and effective partnerships.

61
Case Managers Say
  • One-third of my caseload shows symptoms of
    depression, it is an important issue to address.
  • It was hard to add one more thingbut seeing
    our clients respond ...this is worthwhilewe are
    actually empowering them.
  • With Healthy IDEAS case managers are now able to
    offer resources that assist our clients in
    self-management of depressive symptoms. This
    allows us to better serve our clients.
  • I have seen big changes with clients
    participating in Healthy IDEAS including
    increased mobility.

62
Clients Say
  • With the information I have now, I am better
    able to manage my health.
  • I enjoyed doing activities that made my day seem
    better.
  • I understand how my activity affects my mood
    now. When I am feeling sad, I go for a walk or
    go out to the local grocery store and I just feel
    better.

63
Taking Action Individual or Agency
  • Take a few minutes to identify what one thing you
    can undertake to
  • Improve depression care for elders in your
    community
  • Maintain a positive, healthy mood in your own life
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