Transcript Prevention Research Centers (PRC)-Healthy Aging Research Network (HAN) Webinar Series Evidence-Based Depression Care Management: Healthy IDEAS October 29, 2008 3:00-4:30 EST Moderated By: Alixe McNeill Nancy L.

Prevention Research Centers (PRC)-Healthy
Aging Research
Network (HAN) Webinar Series
Evidence-Based Depression Care
Management:
Healthy IDEAS
October 29, 2008 3:00-4:30 EST
Moderated By: Alixe McNeill
Nancy L. Wilson,
M.A., LCSW
Pat Gleason-Wynn,
PhD, LCSW, BSN, RN
Sharon Foerster,
LCSW
Sponsors
Prevention Research CentersHealthy Aging Research Network
http://www.prc-han.org/
Retirement Research Foundation
http://www.rrf.org/
National Council on Aging
http://ncoa.org/index.cfm
Presentation Objectives
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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 IDEAS
Identifying
Depression
Empowering
Activities for
Seniors
Accomplished through
Partnerships
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Program Leadership: Care for Elders and Baylor
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+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
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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
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Client Barriers
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Provider Barriers
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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?”
Lack of knowledge and skills
Primary Care faces many competing demands
Scarcity of mental health professionals
System Barriers
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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?
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.
Program Goals
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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 evidencebased 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.
Evidence for Healthy IDEAS
Components
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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
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Program Design
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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
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Screening for symptoms of depression & assessing
severity
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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.
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Two-question screen & standardized assessment
Behavioral Model of
Depression
Depression results in behaviors that limit positive outcomes
→ reduced pleasure, reduced accomplishment
Lowered
Mood
Decreased
Pleasant
Activities
Decreased
Activity
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
Client Intervention Flowchart
New or Existing
Agency Client
Depression Screening
Administered
Two Questions
Positive Screen
Negative Screen
Geriatric Depression Scale (15 item)
Administered
Severe
Depression
Referral to MD
or MH specialist
Mild/Moderate
Depression
No Depression
Behavioral Activation
Offered
Education Offered
Evaluation Design
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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:
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Depression, pain, social function, social and physical
activity levels, education/knowledge, service use
Measured client satisfaction via telephone
interviews.
Client Demographic Profile
Clients Screened (n=327)
Mean Age****
Gender
Race/Ethnicity****
Cognitive Errors
Living Alone
Mean Income**
Education
Comorbidities***
3+ IADL Limitations***
*p≤.05, **p≤01, ***p≤.001, ****p≤.0001
75.9 years old (SD=9.5)
76% female
 Hispanic: 28%
 African American: 43%
 Caucasian: 27%
 Other: 2%
1.4 (SD = 1.4)
67%
$789/month
 6 years or less: 24%
 7–12 years: 55%
13+ years: 21%
3.1 (SD = 1.7)
59%
GDS Positive Clients
(n=94)
72.5 years old (SD=9.4)
80% female
 Hispanic: 44%
 African American: 20%
 Caucasian: 34%
 Other: 2%
1.6 (SD = 1.5)
65%
$846/month
 6 years or less: 23%
 7–12 years: 50%
13+ years: 27%
3.6 (SD = 1.8)
48%
Delivery Experience and
Outcomes
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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
Client Impact
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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.
GDS Outcomes
(15 item scale)
Scores at 3 and 6 months differ from baseline at p < .0001
9
8
7
6
5
9
4
3
6
2
5.5
1
0
Baseline
3 months
6 months
Clients Reporting Pain
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
None-Mild
Moderate-Severe
Severe-Very Severe
Baseline
6 months
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
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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?
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Need and Opportunity
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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
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Consumer Need had previously been identified
 60% with mental health diagnosis
HI a good match
 Depression focus
 Case management relationship with home visits/Fidelity
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History and Current Status
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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…
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Leadership
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Started at leadership – buy-in
Commitment at all levels of agency administration
necessary
Staff champions
Community Partners
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Outside people bring another level of credibility
“proof” it had been successfully done before
Dedicated Staff
Tools to follow
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Curriculum Model
tool also developed by staff: crucial for data collection,
ease anxiety
What it took to make it work …
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Organizational Commitment
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Leadership, Readiness for Change
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Champions!
Staff Preparation and Planning
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Especially if a role change
Communication, training, break down own
biases, belief, identify barriers
Belief!
What it took to make it work …
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Staff Preparation, Planning & Support
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Trainings Provided
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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
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Grant monies used mainly for all above
Characteristics of Clients with
positive GDS scores (N=80)
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Of the 80 who screened in:
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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
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Eighty (80) screened in
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Forty-three (43), 54%, had GDS Score of 6 or
above and eligible for the Behavioral
Activation
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24 (56%) agreed to do the BA intervention
23 (53%) had a referral to physician or mental
health counselor
“Lessons Learned”
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Perfection not the Goal
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Learning is the Goal
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Redefines type of pressure/learning curve
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
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Prevention/health promotion, self-management
aspect to depression, connection of mood to
activities
Consumer Outcomes
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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
Consumer Outcomes
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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
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Knit caps, puzzles, look at her garden
6 month GDS score was 6
Consumer Outcomes –
CM Impact
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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
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Staff Role Change
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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.)
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Consumer depression signs addressed
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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
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Sharon Foerster, L.C.S.W.
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Director, Elder Independence of Maine
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A division of SeniorsPlus, Area Agency on Aging
[email protected]
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)
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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
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Total County Population: about 1.7 million
Population age 60 and over: over 200,000
“Great Place to Grow Old”
Decision to Implement
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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
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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
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Agencies: AAA, Catholic Charities, Meals on
Wheels, MHMR, and MHA
Training: 12
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hours
22 professionals including
administrators, students from agencies
[outcome: 7 active case managers]
2 “booster” meetings – May, September – 2
hours
Stage 2: Implementation
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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
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Implementation
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Agencies: AAA, Catholic Charities, Meals
on Wheels, Senior Citizen Service
Training: 8 hours
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17 professionals including administrators and
students [outcome: 13 active case managers]
Booster Meeting scheduled for December
Implementation: Case
Managers
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20 case managers actively involved
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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)
Mean Age
74.3 years
Gender
58% Female
n=62
Race/Ethnici  Hispanic: 6.5% (n=7)
ty
 African American:
30.4% (n=33)
 Caucasian: 62.6%
(n=67)
GDS Positive Clients
(n=22)
74.2 years
59% Female
n=13
 Hispanic: 9% (n=2)
 African American:
18% (n=4)
 Caucasian: 72.7%
(n=16)
Examples-Behavioral
Activation
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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
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Of the 22 clients with a GDS score of 5
or higher:
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18 clients agreed to participate in Behavioral
Activation
90-day Follow-up Results:
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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
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Mr. M: Initial Visit
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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
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GDS: 8/15, with very severe pain score
Lessons Learned
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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
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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 …
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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.
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Replication report: NCOA-Center for Healthy Aging
website http://www.healthyagingprograms.org
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Care for Elders: www.careforelders.org/healthyideas
Dissemination:
www.careforelders.org/healthyideas
 Organizations
States
 Area Agency on
 Arizona
Aging case
management
 Georgia
programs
 Maryland
 Local non-profit
 Maine
social service
 Michigan
agencies
 New Jersey
 Behavioral health
provider agencies
 Ohio
 Caregiver
 Texas
support programs
 Vermont
Contact: [email protected]
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Questions & Answers
Future PRC-HAN Webinars
All 3:00-4:30 pm EST
Relevant to all Evidence-based
Programs
Thursday, November 13th Money Matters
To Register:
http://ncoa.org/content.cfm?sectionID=64