Adapting Collaborative Depression Care for Public Community Long-Term Care: Using Research-Practice Partnerships

Implementing evidence-based treatments in practice settings can be difficult, with interventions often needing adaptation to work in the real-world.¹ One understudied strategy for implementation is engaging multiple stakeholders in bringing evidence-based intervention into practice settings. In the present article, Hasche and her colleagues present a case study to demonstrate how these stakeholder partnerships can aid in the successful implementation of evidence-based treatment into practice.

The Case

Community Long-Term Care

Community long-term care (CLTC) services are targeted toward low-income older adults to assist with chronic conditions while helping them continue living in the community.² CLTC workers often serve as integral contact persons for biopsychosocial resource referrals.³ One potential need for service referral is depression with rates of depression to be disproportionately high in CLTC clients.⁴ Unfortunately, depression frequently goes undiagnosed in this population, possibly in part due to clients’ competing demands presented to the CLTC worker.⁵ In 2000, researchers partnered with a publicly-funded CLTC in a Midwestern state to identify challenges in implementing evidence-based practice with depression into CLTC.

Collaborative Care

Given evidence supporting collaborative care for older adult depression treatment,⁶ the research team drew from two existing treatment models to inform collaborative depression care in CLTC: the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) model⁷ and the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) model.⁸ Keeping in mind multi-level barriers to service implementation, researchers and practitioners were appointed to a team tasked with directing the adaptation of the existing models. The team’s overarching goal was to implement a sustainable and effective model in CLTC following adaptation.

The Adaptation

Adaptations were based on four main factors: 1) eligibility and screening (i.e., for levels of depression); 2) treatment procedures (i.e., for clients with comorbid problems); 3) tracking methods for outcome evaluation (i.e., client-provider contact); and 4) communication protocols (i.e., with providers across service systems). The adapted model was pilot tested between May 2007 and September 2008, with initial findings indicating CLTC worker and client support for the adapted model.

Implications

Through this research-practice collaboration, the team made ongoing adaptations, the success of which the authors attribute to shared problem-solving goals and open communication among team members. Despite its successes, the collaboration did see challenges. For example, when NIH grant funding was exhausted, financial sustainability was threatened; the partnership was able to continue due to additional grant writing and policy advocacy. Despite its challenges, the authors assert that, given the unique demands of real-world service provision, future research-practice collaborations should be sought, both for gerontology as well as other social service areas.

For More Information

For a detailed overview of the adaptation of depression treatment for CLTC, read the full article, available in Administration and Policy in Mental Health and Mental Health Services Research. To learn more about Dr. Hasche and her work, visit her GSSW faculty page or DU portfolio.

Citation

Hasche, L. K., Lenze, S., Brown, T., Lawrence, L., Nickel, M., Morrow-Howell, N., & Proctor, E. K. (2013). Adapting collaborative depression care for public community long-term care: Using research-practice partnerships. Administration and Policy in Mental Health and Mental Health Services Research. Advanced online publication. doi: 10.1007/s10488-013-0519-z

References

¹ World Health Organization. (2009). Practical guidance for scaling up health service innovations. Geneva: World Health Organization Press.

² O’Shaughnessy, C. V. (2008). The Aging Services Network: Broad mandate and increasing responsibilities. Public Policy and Aging Report, 18(3), 1-18.

³ President’s New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health in America—Final Report (DHHS Publication No. SMA-03-3832), Rockville, MD.

⁴ Morrow-Howell, N., Proctor, E K., Choi, S., Lawrence, L., Brooks, A., Hasche, L., et al. (2008). Depression in community long-term care: Implications for intervention development. Journal of Behavioral Health Services and Research, 35, 37-51. doi: 10.1007/s11414-07-9098-7

⁵ Proctor, E., Hasche, L., Morrow-Howell, N., Shumway, M., & Snell, G. (2008). Perceptions about competing psychosocial problems and treatment priorities among older adults with depression. Psychiatric Services, 59, 670-675. doi: 10.1176/appi.ps.59.6.670

⁶ Gilbody, S., Bower, P., Fletcher, J., Richards, D., & Sutton, A. J. (2006). Collaborative care for depression: A cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine, 166, 2314-2321. doi: 10.1001/archinte.166.21.2314

⁷ Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Hunkeler, E., Harpole, L., et al. (2002). Collaborative care management of late life depression in the primary care setting: A randomized controlled trial. Journal of American Medical Association, 288, 2836-2845. doi: 10.1001/jama.288.22.2836

⁸ Ciechanowski, P., Wagner, E., Schmaling, K., Schwartz, S., Williams, B., Diehr, P., et al. (2004). Community-integrated home-based depression treatment in older adults: A randomized controlled trial. Journal of American Medical Association, 291, 1569-1577. doi: 10.1001/jama.291.13.1569

Does Identification of Depression Affect Community Long-Term Care Services Ordered for Older Adults

Background

Community long-term care (CLTC), available in every state, provides funding for services (e.g., personal care, meal delivery, relief for caregivers) for low-income older adults at risk for nursing home placement. Previous research has found that nearly 25% of CLTC clients suffer depression and typically demonstrate low use of mental health services.¹ Moreover, when depression goes undetected, there is an increased risk for disability and mortality, particularly among older adults.^2,3 In the present study, Hasche and her colleagues examine whether or not the identification of depression influences service authorization in public CLTCs. Authors paid particular attention to competing demands (i.e., total number of health problems, overall level of care needed, cognitive impairment, and number of medications) that had the potential to influence a CLTC worker’s decision to authorize services.

Methods & Sample

CLTC workers approached eligible clients (over 60 years old, English-speaking, were their own  legal guardians), of which 1,508 agreed to participate. Phone interviews were conducted with all clients who met depression criteria (n=299) and a random sample of non-depressed older adults (n=315); several participants were excluded for not returning client-release forms, leaving a final analytic sample of 533. Using self-report interview data and case files for CLTC clients between October 2000 and May 2003, researchers determined 1) whether or not the participant’s CLTC worker noted client depression; 2) type and amount of services authorized; 3) competing demands; and 4) sociodemographic variables. Selected sample characteristics are as follows:

• Age Range: 59-95 years (M=72.51, SD=7.98)
• Gender: 75.42% female
• Race/Ethnicity: 26.08% not White
• Marital Status: 24.39% married
• Monthly Income (in dollars): M=738.41 (SD-338.45)
• Depression noted by CLTC in case record: 15.38%
• Competing Demands:
• Number of Health Problems (0-5): M=1.30 (SD=1.21)*
• Overall Level of Care (4-12): M=8.57 (SD=1.28)*
• Cognitive Impairment (0-12): M=2.88 (SD=2.72)*
• Number of Medications (0-22): M=8.44 (SD=4.18)*

*Higher means (M) indicate higher numbers/levels

Results

Researchers ran three multivariate logistic regressions to determine whether CLTC workers’ depression notation increased the likelihood of service authorization. Each model examined specific services ordered: personal care, homemaker services, and nursing services.

Personal Care

Race, physical health problems, and cognitive impairments were significantly associated with clients being ordered personal care services. Specifically, services were more likely to be ordered for clients who do not identify as White, had more physical health problems, and had fewer cognitive impairments. CLTC workers’ notations of depression were not associated with ordering personal care.

Homemaker Services

Increased age and rural residency were associated with clients being ordered homemaker services. Services were more likely to be ordered for clients who demonstrated less cognitive impairment and took more medications. CLTC workers’ notations of depression were not associated with ordering homemaker services.

Nursing Services

Contrary to the authorization of personal care and homemaker services, notation of depression, as well as number of medications, was significantly associated with the authorization of nursing services. Specifically, CLTC workers were more likely to authorize nursing services for clients who were taking more medications and for whom the worker noted depression.

Implications

Though this study focuses on services ordered, as opposed to service utilization, findings indicate that, even when CLTC workers note depression, older adult clients may still have unmet needs (i.e. personal care, homemaker services). The authors suggest implementing standardized depression screenings for CLTC clients to identify depressed older adults and connect them with appropriate services. Moreover, social workers in non-mental health settings may benefit from additional training in identifying depression and familiarizing themselves with relevant community resources.

For More Information

For more information on CLTC and depression among older adults, you can find this full-text article in Social Work Research, Volume 37. For more on Dr. Hasche’s work, visit her GSSW faculty page or DU portfolio.

Citation

Hasche, L. K., Lee, M. J., Proctor, E. K., & Morrow-Howell, N. (2013). Does identification of depression affect community long-term care services ordered for older adults? Social Work Research, 37(3), 255-262. doi: 10.1093/swr/svt020

References

¹ Morrow-Howell, N., Proctor, E. K., Choi, S., Lawrence, L., Brooks, A., Hasche, L., et al. (2008). Depression in community long-term care: Implications for intervention development. Journal of Behavioral Health Services and Research, 35, 37-51.

² Adamson, J. A., Price, G. M., Breeze, E., Bulpitt, C. J., & Fletcher, A. E. (2005). Are older people dying of depression? Findings from the medical research council trial of the assessment and management of older people in the community. Journal of the American Geriatric Society, 53, 1128-1132.

³ Murray, C. J., & Lopez, A. D. (Eds.). (1996). The global burden of disease. A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020 (Vol. 1). Cambridge, MA: Harvard School of Public Health and the World Health Organization.