Evidence-Based Depression Care Evidence-Based Depression Care Management: Management: Healthy IDEASHealthy IDEAS

Prevention Research Centers (PRC)-Healthy Prevention Research Centers (PRC)-Healthy Aging Research Aging Research

Network (HAN) Webinar SeriesNetwork (HAN) Webinar Series

Nancy L. Wilson, M.A., LCSW

Sharon Foerster, LCSW

Pat Gleason-Wynn, PhD, LCSW, BSN, RN

October 29, 2008 3:00-4:30 EST

Moderated By: Alixe McNeillModerated By: Alixe McNeill

Prevention Research Centers-Prevention Research Centers-Healthy Aging Research NetworkHealthy Aging Research Network

http://www.prc-han.org/

Retirement Research FoundationRetirement Research Foundationhttp://www.rrf.org/

National Council on AgingNational Council on Aginghttp://ncoa.org/index.cfm

Sponsors

Presentation Objectives

Describe origins and key components of Healthy IDEAS

Present program outcomes Discuss steps in implementation

process including key partnerships, funding streams, resources needed

Highlight challenges and lessons from program delivery in two states

HEALTHY IDEASIdentifyingDepression Empowering Activities for Seniors

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

Depression is Common, Disabling & Deadly

Depression is a recurring, chronic illness Older adults are often under-recognized &

under-treated; great disparities Highest rate of successful suicides Identification of depression is not sufficient Effective methods to identify, evaluate,&

treat depression and improve quality of life are available

Barriers to Addressing Depression in Older Adults

Client Barriers Stigma – “I’m not crazy! I’m not a weak person” Lack of knowledge- “ It’s 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

What is Healthy IDEAS?

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.

Healthy IDEASHealthy IDEAS (IIdentifying DDepression, EEmpowering AActivities for SSeniors)

To reach the intended population of frail, high-risk, diverse older adults, often overlooked and under-treated.

To train agency staff to provide and deliver an evidence-based intervention for depression to older adults

To improve the linkage between community aging service providers and health care professionals through appropriate referrals, better communication & effective partnerships.

To insure systematic identification of depression and action through attention to depression screening

embedded into routine case management services.

Program Goals

Evidence for Healthy IDEAS Components

IMPACT AND PEARLS offered the “care management road map “ and evidence for in-home approach

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.)

Systematic Follow-up and Assessment of depressive symptoms

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

Program Design

Embedded in case management programs. Conducted in the client’s home on a one-to-one

basis by case managers over a 3-6 month period. Utilizes existing staff with established relationships

with targeted participants. A manual outlines the steps and includes written

worksheets, client handouts, and forms to support and document the process and client outcomes.

Partner with health/mental health care providers to facilitate referral and uses community partnership approach for training, evaluation & fidelity.

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.

Behavioral Model of Depression

Lowered Mood

Decreased Activity

Decreased Pleasant Activities

Depression results in behaviors that limit positive outcomes

→ reduced pleasure, reduced accomplishment

Behavioral Activation

Rewarding Activities

 

Improved Mood

 

Decreased Depressive Symptoms

      

 

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)

New or Existing Agency Client

Depression Screening Administered

Two Questions Positive Screen Negative Screen

Geriatric Depression Scale (15 item) Administered

Severe Depression

Mild/Moderate Depression

No Depression

Education OfferedReferral to MD

or MH specialist Behavioral Activation Offered

Client Intervention Flowchart

Evaluation Design

Pre-postPre-post impact evaluation data collected. Measures were embedded into agency assessment

& care plan review forms. Data collection occurs according to the routine routine

timeline for case managementtimeline 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 satisfactionclient satisfaction via telephone

interviews.

Client Demographic Profile

Clients Screened (n=327) GDS Positive Clients (n=94)

Mean Age**** 75.9 years old (SD=9.5) 72.5 years old (SD=9.4) Gender 76% female 80% femaleRace/Ethnicity**** Hispanic: 28%

African American: 43% Caucasian: 27% Other: 2%

Hispanic: 44% African American: 20% Caucasian: 34% Other: 2%

Cognitive Errors 1.4 (SD = 1.4) 1.6 (SD = 1.5)Living Alone 67% 65%Mean Income** $789/month $846/monthEducation 6 years or less: 24%

7–12 years: 55%13+ years: 21%

6 years or less: 23% 7–12 years: 50%13+ years: 27%

Comorbidities*** 3.1 (SD = 1.7) 3.6 (SD = 1.8)3+ IADL Limitations*** 59% 48%*p≤.05, **p≤01, ***p≤.001, ****p≤.0001

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

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.

Client Impact

GDS Outcomes (15 item scale)(15 item scale)

9

65.5

0

1

2

3

4

5

6

7

8

9

Baseline 3 months 6 months

Scores at 3 and 6 months differ from baseline at p < .0001

Clients Reporting Pain

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline 6 months

None-MildModerate-SevereSevere-Very Severe

Scores comparing Baseline to 6 months differ at p < .005

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

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.

The Maine Experience

Sharon Foerster, LCSW

Director, Elder Independence of Maine

Webinar – October 29, 2008

Why replicate Healthy IDEAS?

Need and Opportunity EIM Home Care Coordination Agency

Case management (telephone and face to face) Serve consumers throughout the state Community-based population (HCB Waiver services) –

Identify a specific population and specific Care Managers Significant functional limitations

Consumer Need had previously been identified 60% with mental health diagnosis

HI a good match Depression focus Case management relationship with home visits/Fidelity

History and Current Status

Leadership began exploration and planning in April 2007 Fifteen (18) Staff (case managers, supervisors, managers)

trained how to deliver intervention in October 2007 CM Staff (RNs and LSWs) began screenings in November

2007 (pilot first in Oct 07) 343 population of HCB older adult consumers 102 not approached

cognitive level, non-communicative, GDS not available in primary language (Somali)

191 screened between November 2007 and April 2007 GDS two question screen 80 screened in (GDS positive) (42%)

What it took to make it work…

Leadership Started at leadership – buy-in Commitment at all levels of agency administration

necessary Staff champions Community Partners

Outside people bring another level of credibility “proof” it had been successfully done before

Dedicated Staff Tools to follow

Curriculum Model tool also developed by staff: crucial for data collection,

ease anxiety

What it took to make it work …

Organizational Commitment Especially if a role change

Leadership, Readiness for Change Champions!

Staff Preparation and Planning Communication, training, break down own

biases, belief, identify barriers Belief!

Staff Preparation, Planning & Support Trainings Provided

Change Process Acknowledged barriers to change/concerns Encouraged problem-solving

Depression in Older Adults Role clarification crucial, confronted own biases

Geriatric Depression Scale (GDS) Practice, practice, practice

Healthy IDEAS Model Finally – they can practice the model!

Ongoing Consultant once screenings began Motivational Interviewing Techniques/Timing

Grant monies used mainly for all above

What it took to make it work …

Characteristics of Clients with positive GDS scores (N=80)

Of the 80 who screened in: 74% female 98% Caucasian 82% high school grad or less 65% receiving treatment for depression 41% in category of severe score on the GDS

(GDS score greater than 10) Mean Age = 70 years

Consumers Who Screened in

Eighty (80) screened in Forty-three (43), 54%, had GDS Score of 6 or

above and eligible for the Behavioral Activation

24 (56%) agreed to do the BA intervention 23 (53%) had a referral to physician or mental

health counselor

“Lessons Learned”

Perfection not the Goal Redefines type of pressure/learning curve

Learning is the Goal demonstration grant/reminders/new skills

Communication Adequate Support needed/no additional staff but still

need time & resources Motivational Interviewing great addition/timing “Therapy” not always “the” answer

Prevention/health promotion, self-management aspect to depression, connection of mood to activities

Consumer Outcomes 81 yr old female with significant arthritis, anemia, renal

insufficiency, and long standing history of depression. Family members report she would “often be snippy” with them.

Scored a 12 on GDS (out of 15), moderate to severe cons was willing to do HI Behavioral Activation to improve

her mood.  Chose activities and work with physician Effects on family dynamics Reported Outcome: She reported that she was doing much

better with interactions with family and enjoying more quality time with them.  She also was getting out more. 

6 month GDS score was 7

77 year old with history of stroke. No use of one side of her body, transfers via hoyer lift. 

Family reported she was not motivated to do anything.  When approached with HI and discussion of mood,

consumer feared NF placement.  Scored 9 on GDS and after much discussion (use of

MI), agreed to participate in HI Behavioral Activation.  Family was supportive and helped her to work on her

goals.  Chose activities enjoyed previous to the stroke, but

given up Knit caps, puzzles, look at her garden

6 month GDS score was 6

Consumer Outcomes

Consumer Outcomes – CM Impact

77 y/o man recent stroke Scored in and chose to try Behavioral

Activation Chose goal of wife reading aloud to him Case Manager thought this goal was “too

passive” and would not make a true difference Hindsight: understood how goal was

meaningful

The BIG Success

Staff Role Change Shift to mental health focus Greater awareness of depression in older adults Depression “OK” to talk about, “I think about

consumers differently” Staff developed the tool for organizing the work

(from the HI training module) Positive Outcomes basis for Policy Change: Need

to embed EBP into waiver programs, added value in payment structure for this case management model

Big Success (Cont’d.)

Consumer depression signs addressed Staff: More than therapy and medication as

intervention Consumers: learn self-management along with other

resources Family Members grateful “System:” Prevention is key HI EBP is “marriage” of science and service: staff see

improvement

Contact Information

Sharon Foerster, L.C.S.W. Director, Elder Independence of Maine

A division of SeniorsPlus, Area Agency on Aging sfoerster@elderindependence.org 207-795-7213 P.O. Box 659, Lewiston, ME 04243

Healthy IDEAS In Fort Worth

Pat Gleason-Wynn, PhD, LCSW, BSN, RN

Healthy IDEAS Team Leader

Area Agency on Aging of Tarrant County

Webinar – October 29, 2008

Healthy IDEAS (HI)

Initiative of the Area Agency on Aging (AAA) and United Way of Tarrant County, Texas

Located in Fort Worth, Texas; Tarrant County; North Central Texas Total County Population: about 1.7 million Population age 60 and over: over 200,000 “Great Place to Grow Old”

Decision to Implement

High prevalence of isolated older adults with depressive symptoms

HI is an evidence-based program focusing on depression & older adults, with demonstrated effectiveness

Infrastructure present in Tarrant County to implement the program among existing case management services; high collaboration

Stage 1: Pilot Project

March to September 2008 Funding Stream: In-kind

Contributions (Time & Materials) Agencies: AAA, Catholic Charities,

Meals on Wheels, MHMR, and MHA My roles: Trainer, Coach, Organizer

Pilot Project

Agencies: AAA, Catholic Charities, Meals on Wheels, MHMR, and MHA

Training: 12 hours 22 professionals including

administrators, students from agencies [outcome: 7 active case managers]

2 “booster” meetings – May, September – 2 hours

Stage 2: Implementation

October 1, 2008 – Current Stage Agencies: AAA, Catholic Charities, Meals

on Wheels, Senior Citizen Service Funding Stream: Title III B, Older

Americans Act Role Changes – still Trainer, Coach

AAA has assumed role of coordinator/organizer for the 5 agencies

Implementation

Agencies: AAA, Catholic Charities, Meals on Wheels, Senior Citizen Service

Training: 8 hours 17 professionals including administrators and

students [outcome: 13 active case managers] Booster Meeting scheduled for December

Implementation: Case Managers

20 case managers actively involved 50% have social work degrees, remaining

have degrees in related fields Wide variance of experience: 3 wks to 16

years 4 different agencies involved with 2 other

agencies serving as resources

Pilot Project Outcomes:Demographics

Clients Screened (n=107)

GDS Positive Clients (n=22)

Mean Age 74.3 years 74.2 yearsGender 58% Female

n=6259% Female n=13

Race/Ethnicity

Hispanic: 6.5% (n=7) African American: 30.4% (n=33) Caucasian: 62.6% (n=67)

Hispanic: 9% (n=2) African American: 18% (n=4) Caucasian: 72.7% (n=16)

Examples-Behavioral Activation

Go outside on scooter, 15-30 minutes daily Pick one and go with wife: doctor appt, store,

restaurant Visit with selected neighbor, 1 x wk Work on puzzles, 3 x wk for 30 minutes Walking with Walking Club, Walk daily Go to Senior Center Compile photo albums Tending to plants Writing in journal

Pilot Project Outcomes:Results

Of the 22 clients with a GDS score of 5 or higher: 18 clients agreed to participate in Behavioral

Activation 90-day Follow-up Results:

12 had decrease in GDS scores by 1-3 points 3 clients maintained 2 unable to obtain scores 1 caregiver showed an increase

Story of Mr. M

Mr. M: Initial Visit 78 year old, Hispanic male, dx: Leukemia GDS: 10/15, with severe pain score Receptive to HI, and Behavior Activation Wife receiving Caregiver Counseling AAA

Mr. M: 90-day Follow-up GDS: 8/15, with very severe pain score

Lessons Learned

HI is effective modality – it WORKS! Program can be implemented across

agencies, unified funding stream Frequent contact (email, phone, booster

meetings) between coordinator and case managers important

Future Plans

Plan to continue Healthy IDEAS; and, anticipate serving at least 350 clients this fiscal year

Implement User Group on Google for discussion and idea sharing among case managers

“Booster” meeting is scheduled for December 4 for all active case managers

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 26:139-156.

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/healthyideas

Dissemination: www.careforelders.org/healthyideas

States Arizona Georgia Maryland Maine 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 programsContact: esteinberg@shelteringarms.org

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